The American College of Cardiology (ACC) is expected to update its recommendations for evaluation of chest pain to include coronary CT angiography (CCTA) as a first line study. If this happens, it will represent a seismic shift in the diagnostic strategy for coronary artery disease. Functional imaging, primarily single photon emission tomography (SPECT), has long been the mainstay, largely based on the understanding that coronary artery stenosis does not always correlate with ischemia.

The change appears to be driven by a report from a summit organized by the ACC. ^[1] Poon M, Lesser JR, Biga C, et al. Current evidence and recommendations for coronary CTA first in evaluation of stable coronary artery disease. J Am Coll Cardiol. 2020;76(11):1358-62. The report cites data from Truven Health Analytics* showing a higher rate of subsequent intervention (cardiac catheterization and revascularization) when functional imaging is used as a first line study (vs. CCTA). In addition to a cost advantage, the authors point to several recent clinical trials that would favor a ‘CCTA first’ approach. Among these were the SCOT-HEART trial and the PROMISE trials suggesting that early knowledge of the presence of plaque led participants to seek treatment and to implement healthy lifestyle changes.

A recent decision by Cigna and other payers to drop prior authorization requirements for CCTA appears to be linked to the report. It is not clear whether others will follow suit, or whether the ACC will provide specific guidance on how CCTA fits into a larger diagnostic strategy. 

Dr. Thomas Power, National Medical Director of Cardiology, Sleep Medicine, and Surgical Procedures for Carelon, notes that “the shift to a CCTA first approach will have to be gradual. Aside from the challenge of changing provider ordering behavior, there are other issues to be addressed. Currently there is not enough CCTA capacity and there is a shortage of providers trained to interpret CCTA. Nonetheless, this is an exciting first step in how we approach the management of CAD.”