Chest Pain Implications

The major cardiac imaging societies weighed-in on the AHA/ACC’s new Chest Pain Guidelines, highlighting the notable shifts coming to cardiac imaging, and the adjustments they could require.

The cardiac CT and MRI societies took a victory lap, highlighting CCTA and CMR’s now-greater role in chest pain diagnosis, while forecasting that the new guideline will bring:

  • Increased demand for cardiac CT & MR exams and scanners
  • A need for more cardiac CT & MR staff, training, and infrastructure
  • Requests for more cardiac CT & MR funding and reimbursements
  • More collaborations across radiology, cardiology, and emergency medicine

The angiography and nuclear cardiology societies were less celebratory. Rather than warning providers to start buying more scanners and training more techs (like CT & MR), they focused on defending their roles in chest pain diagnosis, reiterating their advantages, and pointing out how the new guidelines might incorrectly steer patients to unnecessary or insufficient tests.

FFR-CT’s new role as a key post-CT diagnostic step made headlines when the guidelines came out, but the cardiac imaging societies don’t seem to be ready to welcome the AI approach. The nuclear cardiology and radiology societies called out FFR-CT’s low adoption and limited supporting evidence, while the SCCT didn’t even mention FFR-CT in its statement (and they’re the cardiac CT society!).

Echocardiography maintained its core role in chest pain diagnosis, but the echo society clearly wanted more specific guidelines around who can perform echo and how well they’re trained to perform those exams. That reaction is understandable given the sonographer workforce challenges and the expansion of cardiac POCUS to new clinical roles (w/ less echo training), although some might argue that echo AI tools might help address these problems.

The Takeaway

Imaging and shared decision-making play a prominent role in the new chest pain guidelines, which seems like good news for patient-specific care (and imaging department/vendor revenues), but it also leaves room for debate within the clinic and across clinical societies. 

The JACC seems to understand that it needs to clear up many of these gray areas in future versions of the chest pain guidelines. Until then, it will be up to providers to create decision-making and care pathways that work best for them, and evolve their teams and technologies accordingly.

Chest Pain Imaging Guidance

If it seemed like coronary imaging folks were more excited than usual last week, it’s because the AHA/ACC’s long-awaited chest pain guidelines just set the stage for a lot more imaging.

The Guidelines – The American Heart Association (AHA) and the American College of Cardiology (ACC) released their first clinical guidelines for the assessment and diagnosis of chest pain, outlining a range of new standards, processes, and pathways, while giving coronary imaging a central diagnostic role.

Front-Line Coronary CTA – The new guidelines made coronary CTA a front-line coronary artery disease test, assigning CCTA their highest recommendation level and proposing it for a large group of patients (mid-high risk of CAD, stable chest pain, <65yrs).

FFRct Next in Line – HeartFlow’s FFRct analysis will often serve as the next diagnostic step when CCTA exams reveal obstructive CAD (40-90% stenosis) or are inconclusive, with FFRct results either clarifying diagnosis or supporting treatment decisions. 

Stress Imaging Pathways – The AHA/ACC guidelines also gave stress imaging (e.g. TTE, echo, CMRI, PET, etc.) their highest recommendation level, positioning stress imaging for more serious cases (likely or confirmed obstructive CAD, ≥65yrs) as well as for diagnosing myocardial ischemia and estimating risks of major cardiac events among patients with less severe cases (intermediate risk, no known CAD, acute chest pain).

Takeaway – These new guidelines are a big deal for coronary imaging, given the millions of people who show up at US emergency departments with chest pain each year. It’s also going to require some big changes across EDs, imaging centers, and radiology departments/practices, who will have to retool their imaging protocols/fleets and be able to expertly interpret a wave of coronary imaging exams (and handle a wave of incidentals).

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-- The Imaging Wire team