Heart disease remains the leading cause of death worldwide, yet many people are unaware they're at risk until it's too late. As a cardiologist, I've seen countless patients whose heart disease went undetected by traditional stress tests. While these tests are common, they often miss critical warning signs, leaving lives hanging in the balance. That's why I've become a strong advocate for CT coronary angiography (CCTA) as the initial test for most patients with suspected heart disease.

The Power of CCTA

CCTA provides a comprehensive view of the coronary arteries, allowing us to detect disease earlier and more accurately than stress tests. Here's why I believe it's superior:

1. Unparalleled Accuracy
   CCTA has consistently shown higher sensitivity and specificity for detecting coronary artery disease compared to stress tests. In the CORE-320 trial, CCTA demonstrated a sensitivity of 92% versus just 62% for SPECT imaging (1).
2. Early Detection of Non-Obstructive Plaque
   Unlike stress tests, CCTA can identify non-calcified and low-density plaques, which are often more prone to rupture and cause heart attacks. Studies have shown that CCTA detects coronary atherosclerosis in up to 53% of patients with a calcium score of zero.
3. Reduced Risk of Heart Attacks
   Multiple large-scale studies have demonstrated that CCTA-guided care leads to a significant reduction in myocardial infarctions. A meta-analysis found a 31% lower risk of heart attacks in patients who underwent CCTA compared to standard care.
4. Comprehensive Cardiac Evaluation
   CCTA provides detailed anatomical information about the heart and its vessels, allowing for a more thorough assessment of overall cardiac health.
5. Early detection
   CCTA provides a comprehensive view of the coronary arteries, allowing us to detect disease earlier and more accurately than stress tests.
6. Blood flow analysis
   Additionally, the advent of CT-derived fractional flow reserve (CT-FFR) has enhanced CCTA's utility by providing functional insights into coronary lesions. This integration helps identify patients who truly need invasive procedures, significantly reducing unnecessary heart catheterizations while maintaining excellent patient outcomes.

My Experience

Let me share a recent case that illustrates the power of CCTA. A 50-year-old woman came to me after an incidental finding of coronary plaque on an abdominal CT. She had fatigue going on for years, so never had a cardiac workup. Astute clinicians know that many patients have atypical symptoms and fatigue could be one of these. When we performed a CCTA, it revealed extensive disease - one artery 100% blocked, another 80% blocked, and a third 40% blocked. Without appropriate attention to her fatigue, we would have missed her heart disease.

Overcoming Barriers to CCTA

Despite its clear advantages, some barriers prevent widespread adoption of CCTA:

1. Cost: While CCTA can be more expensive upfront, it often leads to more targeted care and fewer unnecessary procedures, potentially saving money in the long run.

2. Insurance Approval: Many insurers still prefer stress tests. However, with growing evidence supporting CCTA, more are beginning to cover it as a first-line test.

3. Radiation Concerns: Modern CCTA protocols use very low radiation doses, often less than 1 mSv, which is comparable to the background radiation exposure over 3-4 months (2).

4. Availability: Not all facilities have the latest CT technology or experienced readers. However, this is rapidly changing as more centers recognize the value of CCTA.

5. Clinician factors: Depending on your healthcare provider's area of expertise, they may not be aware of the superiority of CCTA over stress tests. Also, a lot of care is driven by insurance and healthcare guidelines driven protocols. These protocols are often optimized for reducing the cost rather than early detection.

What You Should Do

If you're concerned about your heart health, here are the steps I recommend:

1. Discuss CCTA with your doctor, especially if you have risk factors for heart disease.

2. If recommended, schedule a CCTA at a facility with experience in cardiac imaging.

3. Prepare for the test by avoiding caffeine and following any other instructions provided. To get the best pictures with the least radiation, we try to lower the heart-rate below 60 beats per minute using medicines like metoprolol or Corlanor® (ivabradine).

4. After the test, review the results with your doctor to develop a personalized prevention or treatment plan.

5. Follow up regularly and make necessary lifestyle changes to protect your heart health.

What if insurance does not cover the test?

If your insurance does not cover the test, you can opt to pay in cash for the test.

1. Call the Performing Department: Inquire about the CPT codes they typically bill for coronary CT angiography. The common CPT code for CCTA is 75574.

2. Visit MDsave.com: Search for "Coronary CT Angiography" or enter the CPT code 75574 to compare prices from various providers in your area.

3. Check Insurance Coverage: Verify if your insurance covers CCTA. If not, consider using MDsave's pre-negotiated rates for a more affordable option.

4. Schedule Your Appointment: Choose a provider, confirm the quoted price, and schedule your CCTA appointment.

5. Specify Your Preferences: Since CT-FFR (CPT code 75580) can be expensive, clearly communicate to the provider that you do not want CT-FFR included in your examination.

By embracing CCTA as a first-line test, we can detect heart disease earlier, intervene more effectively, and ultimately save lives. Don't leave your heart health to chance – consider CCTA for a clearer picture of your cardiovascular risk.

References:
1. Chen MY, Rochitte CE, Arbab-Zadeh A, Dewey M, George RT, Miller JM, Niinuma H, Yoshioka K, Kitagawa K, Sakuma H, Laham R, Vavere AL, Cerci RJ, Mehra VC, Nomura C, Kofoed KF, Jinzaki M, Kuribayashi S, Scholte AJ, Laule M, Tan SY, Hoe J, Paul N, Rybicki FJ, Brinker JA, Arai AE, Matheson MB, Cox C, Clouse ME, Di Carli MF, Lima JAC. Prognostic Value of Combined CT Angiography and Myocardial Perfusion Imaging versus Invasive Coronary Angiography and Nuclear Stress Perfusion Imaging in the Prediction of Major Adverse Cardiovascular Events: The CORE320 Multicenter Study. Radiology. 2017 Jul;284(1):55-65. doi: 10.1148/radiol.2017161565. Epub 2017 Mar 14. PMID: 28290782; PMCID: PMC5495129.

2. Richards CE, Obaid DR. Low-Dose Radiation Advances in Coronary Computed Tomography Angiography in the Diagnosis of Coronary Artery Disease. Curr Cardiol Rev. 2019;15(4):304-315. doi: 10.2174/1573403X15666190222163737. PMID: 30806322; PMCID: PMC8142354.