CT of heart study

[ckent]

Is anybody else's school doing the study where they look at really fast/resolute CT's with computer guidance to evaluate coronary artery disease? My ED/radiology department are doing this as part of their intial evaluation of CP patients. Looks like really cool stuff, could one day replace all diagnostic cardiac cathertizations. My attending told me that other schools were pursuing this study as well so it was kind of a race, so I was just wondering where other schools were in this study.

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[Voxel]

There are two different things going on in cardiac ct at right now.

Our bad ass 0.625mm, 16 slice CT scanner does ekg gated CTA of the coronary arteries. Cardiologists and EM docs are still not used referring patients for cardiac cta. We use it mostly now for checking the patentcy of CABG grafts for our cardiothoracic surgeons. It hasn't replaced diagnostic cardiac cath, yet. You could technically do this on an old(er) 4 slice scanners but the images are so much better using the latest 16 slices scanners with thin sections and fast rotation speeds. We use a 3D workstation to do multiplanar recons on the images in oblique sagital, coronal and axial planes (ie cardiac planes)

The second type of cardiac ct that we do is calcium scoring. Originally it was developed for EBCT (electron beam ct) but now we do it with standard thin slice non-contrast cardiac CT. The gist of this baby is that it is a predictor for coronary events in the next 18-24 months. No calcium means highly unlikely that you will have a coronary event in the near future. >75% above average population calcium score and your relative risk goes way up for your age group.

 

[Voxel]

I think radiologist will read them. However, the main issue is getting EM and cardiologists to refer patients for these studies. Getting EM physicians to do it is possible, however try getting a cardiologist to order one will be difficult due to inherent conflict of interest ($).

 

[Primate]

I just spent 3 weeks on outpatient medicine and one of my attendings sent at least 2 people per day for the calcium scoring study. They all pay out of pocket for the study. The worried well like this sort of thing, and I think their internists (perhaps not cardiologist) will refer for it.

P

 

[ckent]

I was referring to the multi-slice EKG gated CT scan that seems to be the new fad on the street. Rumor is that cardiology groups are starting to purchase these machines so that they can run and interpret them themselves. So long as they control who needs it, they can control who runs it. I suppose that it's a similar situation to why cardiologists do their own echos. Right now, my school's study is being run by ER docs and radiologists though. I suspect that there may be some resistance from cardiologists to taking away their cath cash cow, but change is always inevitable in medicine. I do think that it's neat how everything is becoming radiological though. Eventually, I think that all patients who even step in any ER will get a full body scan. Hopefully, computers will be so advanced then that there won't even need to be a radiologist to interpret it. Before any radiologists get upset at me for saying that, I can't imagine that looking at a bunch of thinly sliced normal scans all day would be very satisfying, even to the most hard core radiologist, so I think that computer interpretation would help everybody.

 

[Voxel]

CKent, I hope you're not serious. Cause treating whiny, obsessive-compuslive, neurotic, stingy, drug seeking patients, psychiatric laden, personality disorder patients and getting paid peanuts to see them is not my idea of fun, more like eternal medicine. So please don't run your mouth off in our house. As hard as it may seem to you, I enjoy my work and the includes looking at normal cases. It helps you understand what normal, normal varients and pathologic disease look like and the differential dx for pathologic findings. I could go off on a discussion on how easy it would be for computers to do eternal medicine once the diagnosis is made, but I won't go there.... and I won't go posting it in the internal medicine forum either.

Buh-bye.

 

[RADRULES]

I agree... get lost with all of this computer reading bullsh*t.

As for cardiac imaging, it is certainly the cutting edge of radiology right now, with cardiac CT and MR. Cardiologist will no doubt try to get their greedy little hands on it. I can't think of a group of physicians more driven by $$$ than cards. How many unnecessary caths are performed per year?? They will continue to steal all of our innovations until we stop them.

We should all remember than WE are the imaging experts and WE must control our turf. But the problem will always be that we don't control the patients.

In any case, eliminating cardiac caths would be very good for patients, but very bad for the bottom line of the cards guys. They may have to give up one of their country club memberships or something, god forbid. I expect them to put up a good fight.

 

[doc05]

Originally posted by RADRULES
In any case, eliminating cardiac caths would be very good for patients, but very bad for the bottom line of the cards guys. They may have to give up one of their country club memberships or something, god forbid. I expect them to put up a good fight.

funny that you criticize cards for being "greedy," when in fact some of the most money-hungry residents are those in radiology.

 

[ckent]

I really didn't mean to offend anybody with that computer interpretation remark; a similar remark was actually made by one of the attending radiologist's today when he was giving a talk about the study. He said that the amount of calcium in the coronary arteries would be quantified by computer, and that the ER resident running the project and other ER residents should not have any difficulty interpreting the degree of stenosis in the coronary arteries thanks to computer interpretation without a radiologist present. Someone will ultimately always need to make the diagnosis, and in my previous post, when I was posting about reading normal scans, I was only referring the high volume of films that would need to be interpreted if we did eventually scan everybody who stepped in the ER, I just think that it would make everybody's life easier (including radiologists) if computer technology got to the point where computers could at least highlight or flag pathology that they "interpret". I know that I don't like to see "healthy" patients (eg patients with the sniffles) when I am working in the hospital, I just assumed that radiologists didn't like to read normal scans all day, but I guess that I was mistaken. And computer interpretations are also very wide spread in medicine as well, we always get our ECG's with a preliminary computer interpretation (which is often wrong for some reason, but I think that the technology will eventually improve to the point that you won't need a cardiologist to read ECG's too as you program every possible algorithm in their computers). Computers are definitely the wave of the future, I look forward to the day when they do turn medicine into a series of protocols that anybody could follow. Doesn't mean that docs will be out of a job, it will probably just mean that clinical guidelines would be adhered to at a much higher rate then they currently are being adhered to. Anyways, I digress, my original intention in this thread was just to get a feel for where other programs were in completing this study because I understand that several major institutions are competing to be the first to publish. It's definitely very exciting stuff, since it will no doubt drastically change ER/medicine/cardiology management of the so many chest pain patients we admit every day.

 

[RADRULES]

"funny that you criticize cards for being "greedy," when in fact some of the most money-hungry residents are those in radiology."

What are your remarks based on??? Pure utter bullsh*t, that is what.

I would gladly give you links to salary lists which show interventional cardiologists are the top earners in medicine. How do you think this happens, by only performing indicated cardiac caths???? If you think that, you are not only ignorant of the way private practice medicine work, but very naive. The number of unnecessary caths done in the private world is SHOCKING. I know, my uncle got one for no good reason. These are not risk free procedures, especially in the hands of those hacks. Cardiologist are the greediest doctors in medicine hands down. I hope we do put those turds out of business.

 

[Santiago]

We had a CME on cardiac CT/MR the other day and the speaker said that allover the world more than 80% of these units were owned by Cardiologists.It's plain greed if nothing else.....
Regards

 

[Santiago]

Also on a postscript,viability imaging by MR is the next best thing.After all,evaluating coronary arteries is distant second to actually evaluating viable cardiac tissue.And,estimating fatty plaques is more important than calcium scoring after all,they are the deadly ones that embolize.Doing HU on the plaques is more imp and detremining their nature is more imp than calcium scoring.What do others feel???Though the cardilogists are hell bent on ordering the calcium scores.I guess they should be educated more regarding this.
Regards