By 2050, the prevalence of total cardiovascular disease in the United States is projected to grow from 11% to 15%. That growth is already felt by doctors, as nearly 8 million patients annually show up to emergency departments with acute chest pain. When those patients present, we need a quicker, more effective way to test for cardiovascular disease.

Currently, the two tests most often performed are stress testing and cardiac catheterization.

While effective, these tests cost time, money, and effort — sometimes, only to find out they were unnecessary. Too many patients endure slow, costly, invasive pathways before we even confirm that they have coronary artery disease(CAD).

That is why I believe that the first step should be coronary CT angiography(CCTA).

A New Standard of Care

We can do better than relying on stress testing and symptom-based referrals as a first line of defense. Chest pain alone is an imperfect indicator of CAD, and sending patients for catheterizations on the basis of this symptom may end up putting them through unnecessary duress. Right now, we’re seeing 1 million cardiac catheterizations performed annually. We could avoid a fair amount of those if we prioritize a CCTA-first approach.

For over two decades, I’ve been passionate about cardiac CT. This advanced imaging technique uses a lower dose of radiation with imaging conducted within a single heartbeat that scans the entire heart. We receive a real picture of what goes on inside the coronary arteries, quickly revealing what we’re treating. This allows us to proactively identify problems and provide patients with the treatment they need.

Noninvasive and fast, CCTA allows for the confident diagnosis of atherosclerosis and anatomical stenoses, enabling more effective titration of medical therapy and referral to invasive angiography, leading to improved revascularization. It opens a door to the entire picture of a patient’s condition instead of just cracking open a window, helping us diagnose CAD, informing us of any patient risks, and improving medical management.

Why CT?

I’ve seen the effectiveness of a CT-first approach firsthand. Back in 2019, we installed a dedicated, small-footprint CT from Arineta at the University of British Columbia. To this day, I’m amazed when I walk into our CT scan room and, instead of a vast unit, see a much smaller piece of equipment on hand to provide the answers.

At the time, I believed that we’d see a rapid adoption of CCTA, but it wasn’t until the 2021 ACC/AHA chest pain guidelines were released that we saw it take off.

Published jointly by a number of professional societies, including the American Heart Association (AHA) and the American College of Cardiology (ACC), the guidelines are used by a wide range of healthcare professionals and organizations, such as the Centers for Medicare & Medicaid Services. Cardiac CT received a Class I, Level A recommendation, validating it as a frontline strategy for diagnosing CAD, supported by evidence from clinical trials.

This top-tier recommendation for cardiac CT as the preferred initial strategy for patients with chest pain and no known CAD is all the more reason to embrace a CT-first approach.

Looking to the Future

We can improve on the current method of sending patients for stress testing or waiting on cath lab appointments; just look at the 50% of patients we’ve seen incompletely revascularized in the ISCHEMIA trial. By implementing a CT-first approach, we can enhance patient outcomes and experiences, while saving them time and money.

The recent position paper  from the Society for Cardiovascular Angiography & Interventions and the Society of Cardiovascular Computed Tomography, which I co-chaired, highlights opportunities to integrate noninvasive physiology, such as fractional flow reserve (FFR-CT) and AI-enabled quantitative atherosclerosis measures into CCTA. We are also seeing growing integration of quantitative plaque assessment in prevention clinics. This broader application through the integration of advanced analytic tools should drive further improvements in clinical outcomes.

I’m confident that cardiac CT will be a standard in cath labs and prevention clinics within the next 10 years.

Jonathon A. Leipsic, MD, is a professor and chair of radiology and a professor of cardiology at the University of British Columbia, and previously served as Canada Research Chair of Cardiac Imaging. Dr Leipsic has over 900 peer-reviewed manuscripts in press or in print. He is also past president of the Society of Cardiovascular Computed Tomography and was awarded its Gold Medal in 2019. Dr Leipsic has received the prestigious top 1% most impactful scientists designation by the Web of Science for the past 6 years.