Krishna Patel, MD, and Leslee Shaw, PhD, in an editorial on the PRECISE study.

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Cardiac Imaging

Fine-Tuning Cardiac CT

CT has established itself as an excellent cardiac imaging modality. But there can still be some fine-tuning in terms of exactly how and when to use it, especially for assessing people presenting with chest pain. 

Two studies in JAMA Cardiology tackle this head-on, presenting new evidence that supports a more conservative – and precise – approach to determining which patients get follow-up testing. The studies also address concerns that using coronary CT angiography (CCTA) as an initial test before invasive catheterization could lead to unnecessary testing.

In the PRECISE study, researchers analyzed 2.1k patients from 2018 to 2021 who had stable symptoms of suspected coronary artery disease (CAD). Patients were randomized to a usual testing strategy (such as cardiac SPECT or stress echo), or a precision strategy that employed CCTA with selected fractional flow reserve CT (FFR-CT). 

The precision strategy group was further subdivided into a subgroup of those at minimal risk of cardiac events (20%) for whom testing was deferred to see if utilization could be reduced even further. In the precision strategy group….

• Rates of invasive catheterization without coronary obstruction were lower (4% vs. 11%)
• Testing was lower versus the usual testing group (84% vs. 94%)
• Positive tests were more common (18% vs. 13%)
• 64% of the deferred-testing subgroup got no testing at all
• Adverse events were higher, but the difference was not statistically significant

To expand on the analysis, JAMA Cardiology published a related study that further investigated the safety of the deferred-testing strategy at one-year follow-up. Researchers compared adverse events in the deferred testing group to those who got the usual testing strategy, finding that the deferred testing group had…

• A lower incidence rate of adverse events (0.9 vs. 5.9)
• A lower rate of invasive cardiac cath without obstructive CAD per 100 patient years (1.0 vs. 6.5)

The results from both studies show that a strategy of deferring testing for low-risk CAD patients while sending higher-risk patients to CCTA and FFR-CT is clinically effective with no adverse impact on patient safety.

The Takeaway
The new findings don’t take any of the luster off cardiac CT; they simply add to the body of knowledge demonstrating when to use – and not to use – this incredibly powerful tool for directing patient care. And in the emerging era of precision medicine, that’s what it’s all about.

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The Wire

• CCTA Predicts Plaque Risk: Meanwhile, in Radiology researchers used CCTA to predict which plaques were most likely to result in major adverse cardiac events (MACE) in patients with non-ST-segment elevation (NSTE) and acute coronary syndrome. In a study of 342 people from 2017 to 2019 scheduled for invasive angiography, plaques with lipid core burden greater than 2.8% were far more likely to lead to MACE (HR=12.6). The findings support use of CCTA for plaque characterization in NSTE patients, even after revascularization.  

• Rad AI Targets Radiology Reporting: Rad AI plans to enter the radiology reporting segment with the launch of Rad AI Omni Reporting. Rad AI will release details of the launch on September 27, but rumors are that the software will take on some of the heavy hitters in the reporting software segment. The company already markets applications for generating report impressions (Rad AI Omni Impressions), closing the loop on follow-up recommendations (Rad AI Continuity), and dynamic worklists (Rad AI Nexus).

• Reimagining Prostate MRI: Adding MRI to prostate cancer screening can reduce mortality while also eliminating unnecessary testing. In the ReIMAGINE study in BMJ Oncology, UK researchers gave 303 men aged 50-75 MRI scans in addition to PSA testing; 16% had positive scans despite median PSA levels of 1.2 ng/mL, below the 3 ng/mL benchmark for follow-up. In all, 10% had cancer requiring treatment, while only 1% had low-risk cancer that did not need treatment. The findings show MRI could help refine PSA screening.

• MRI Reduces Prostate Biopsies: Meanwhile, prostate MRI was further refined in a new study in JAMA Network Open that found performing MRI in men with moderately elevated PSA levels reduced the number requiring biopsy for prostate cancer. Researchers studied nearly 24k men from 2011 to 2021, finding that adding MRI to the workup reduced negative biopsies (7% vs. 28%) as well as the odds ratio of having a biopsy done (OR=0.84). Researchers say all men with PSA from 3-20 ng/mL should get MRI before biopsy.

• Study Supports Synthetic STIR MRI: A new study in AJNR supports the use of a new deep learning reconstruction algorithm from Subtle Medical for MRI. In a database of 93 patients, researchers found that SubtleSYNTH was able to generate synthetic STIR spine images from sagittal T1 and T2 images that five radiologists rated as noninferior to conventional STIR. STIR is a valuable MRI sequence for fat suppression and can highlight pathological changes, but can be time-consuming to acquire; the study validates SubtleSYNTH for faster acquisition.

• FDA Clears Fujifilm 1.5T MRI: The FDA has cleared Echelon Synergy, a 1.5T MRI scanner that Fujifilm Healthcare Americas first debuted at RSNA 2022. The scanner features Fujifilm’s Synergy DLR deep learning reconstruction technology, which leverages AI to speed up scan acquisition and improve image sharpness. Synergy sports a 70cm bore and table load up to 550lb, and also includes the company’s Hydro AG antibacterial coating on high-touch surfaces to reduce healthcare-associated infections.

• AI of Chest X-Rays Predicts COVID Severity: An AI algorithm that analyzed chest X-rays was able to predict which COVID-19 patients would need intensive care treatment. In Journal of Medical Imaging, researchers found that in a population of 5k patients their algorithm was able to predict which patients would need ICU care 24-96 hours in advance after fine-tuning (AUC range=0.76-.0.78). What’s more, patients classified as high risk were 5X more likely to need intensive care.

• Delphinus Raises $12M:  Delphinus Medical Technologies has raised another $12M to support the rollout of its SoftVue 3D whole-breast ultrasound tomography system. The new investment came from Trinity Capital and adds to $30M in funding the firm added last year. SoftVue got approval in 2021 as a supplement to screening mammograms, and Delphinus has been signing clinical partners, including Corewell Health and the University of Rochester Medical Center. 

• ChatGPT Differential Diagnoses Struggles: A Mass General Brigham-led study found that ChatGPT is about 72% accurate in overall clinical decision making, but struggles to make differential diagnoses between similar conditions (60% accuracy). As the study authors put it, that’s an important finding because it tells us “where physicians are truly experts and adding the most value – in the early stages of patient care with little presenting information, when a list of possible diagnoses is needed.”

• TeraRecon Adds Alliances: TeraRecon continues to add new software developers to its Eureka Clinical AI platform, which enables clinicians to launch AI applications from multiple developers. New alliances in recent weeks include Optellum for its Virtual Nodule Clinic solution; Infinitt for its image management software; Gleamer for its BoneView and ChestView algorithms; Mirada Medical for its MiradaXD multimodality nuclear medicine software; ClariPi for its ClariCT.AI, ClariPulmo, and ClariSIGMAM software for lung and breast imaging; and CoLumbo for lumbar spine MRI.

• Ventripoint & Ascend Integrate: Echo AI company Ventripoint Diagnostics announced its integration with Ascend Cardiovascular’s InView diagnostic viewer and Cardiovascular Structured Reporting reporting application, creating an end-to-end cardiovascular workflow. The alliance continues Ascend’s increased focus on echo AI partnerships, coming roughly four months after launching an integration with Us2.ai.

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The Resource Wire

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• What kinds of medical imaging exams are radiologists reading today, and how confident do they feel across different subspecialties? Find out in the 2023 Radiology Practice Development Report from Medality.  

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• In this article in RAD Magazine, learn how Enlitic’s Curie|ENCOG solution uses AI to find metadata and DICOM headers to remove, alter, and protect vital patient information while maintaining clinically relevant data.

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• AI-supported digital applications are expected to transform radiology, but providers need motivation and incentives to adopt them. In this article, authors including executives from Bayer propose a framework to guide payers and AI developers in adoption of radiology AI. 

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• Radiology faces numerous challenges to more efficient workflow, from the siloed nature of healthcare enterprises to mundane tasks that are ripe for automation. In this Imaging Wire Show, we talked to Dr. Matthew Lungren and Calum Cunningham of Nuance Communications.

• Imaging Partners of Orange County was using CD-ROMs to share with patients many of the over 70,000 imaging exams they perform annually. Find out how PocketHealth helped them eliminate CDs and provide a better patient experience.