When it comes to identifying and responding to heart disease, waiting for a patient to present with chest pain is like waiting for someone to develop advanced cancer, instead of pointing it out earlier when treatments may be more effective. While waiting for late-stage disease is not an ideal preventative approach, this approach has nevertheless represented the historical standard of treating heart disease for decades.
Our approach to heart disease has been ineffective, with one person dying of heart disease every 1.7 seconds, and with more than half of all heart attacks occurring in people who do not experience symptoms before the catastrophic event occurs. In part, this failure is due to a focus on indirect surrogate markers for heart disease – such as risk factors (e.g., cholesterol, blood pressure, etc.), symptoms, and stress tests – rather than simply examining the disease itself. The primary disease process is the atherosclerotic plaque, which builds up silently in the walls of the heart arteries over many years.
To improve the prevention of heart attacks, there is an urgent unmet need to modernize our approach from symptom-driven late-stage care to direct disease-based care, a care paradigm that addresses the risk of heart attack in all patients across the entire continuum of heart disease. . We can do this by utilizing non-invasive coronary computed tomography angiography (CCTA) – a fast, safe and accurate approach to evaluating heart disease. Unlike other evaluation methods, CCTA identifies atherosclerotic plaque buildup in all cardiac arteries and their branches, which in previous landmark clinical trials has been shown to be the strongest predictor of a patient’s likelihood of having a heart attack.
In my previous roles as Professor of Radiology and Medicine (Cardiology) at Weill Cornell Medical College and Director of the Dalio Institute of Cardiovascular Imaging at New York-Presbyterian Hospital, I spent more than 15 years trying to better understand and integrate the information that was activated by the CCTA for an approach that could identify individuals at risk for heart attack and treat them effectively. The results of a number of clinical trials support CCTA as an effective first-line tool for evaluating patients with suspected heart disease, and for some time CCTA has been recognized as the leading approach to heart disease evaluation in Europe, Japan and Korea.
The recently updated 2021 clinical practice guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA) and other American professional subspecialty associations are now advocating CCTA as a first-line test for physicians to better evaluate symptomatic patients with suspected heart disease. With CCTA as the new standard of care, we can now advance the diagnostic process, identify patients earlier and with greater accuracy and precision, and treat cardiovascular disease more effectively to improve our patients’ outcomes.
What AHA / ACC guidelines mean for patients
As part of the AHA / ACC guidelines, CCTA was given the highest possible scientific evidence-based designation – Level 1A. This makes it possible to use CCTA across stable chest pain, not only in an outpatient setting, but also for acute chest pain in the emergency room. CCTA is the only modality that has fulfilled the highest designation through a robust and contemporary scientific evidence base of large-scale multicenter and randomized controlled trials. As the only diagnostic approach to achieve this, it replaces recommendations for all other testing methods, including historical approaches such as stress testing.
Furthermore, these new clinical practice guidelines represent the first time the AHA / ACC has recommended atherosclerotic plaque evaluation to assess risk and guide therapeutic decision-making over time, as opposed to traditional speculative methods that use indirect markers or surrogates for heart disease. The new AHA / ACC Clinical Practice Guidelines emphasize the incomparable value of CCTA in guiding both invasive and medical therapies.
Changing the paradigm for heart disease treatment
The use of imaging to guide interventional cardiac therapies is rooted in a strong body of evidence demonstrating the effectiveness of this approach in relieving chest pain and improving quality of life. However, these same clinical trials have shown that a paradigm of diagnostic invasive therapy is ineffective in reducing heart attacks and prolonging life. As a field, we need to separate two questions that we have mistakenly mixed as one: (1) Are my patient’s symptoms related to heart disease? (2) Is my patient at risk for heart attack, and can I treat this effectively with medication and lifestyle interventions, such as diet and exercise? Since the majority of individuals who will suffer from heart attack or sudden coronary death do not actually experience symptoms before their events, the new AHA / ACC guidelines are a major step forward on this path. By prioritizing direct imaging of atherosclerotic disease over more abstract measures, we can fundamentally change the heart disease treatment paradigm to eradicate heart attacks from the earth’s surface. We do not have a treatment problem as there are a number of medical and lifestyle interventions that can reduce heart attacks. We have an identification problem where we do not accurately identify those who are at risk and who need medication and lifestyle changes.
We will undoubtedly see a transition away from stress testing as a first-line approach to diagnosing heart disease with a CCTA-based approach. Given the wealth of information embedded in any individual’s CCTA study, we also have an urgent need for innovative tools that can take the advanced imaging science and translate it into usable clinical insights that improve diagnostic safety for non-imaging clinicians (eg primary care physicians, general cardiologists). etc.) and unlock knowledge for patients through improvements in health competencies. Based on the evidence to date, by targeting each stakeholder in the care paradigm – diagnostic imaging physicians, treating clinicians and patients – the overall cost of care will be significantly reduced and clinical outcomes improved. Ultimately, this approach can improve workflow, reduce costs, improve literacy, and save lives.
Through a CCTA-enabled disease-based approach, early quantification and characterization of heart disease will enable earlier and more effective treatment that can prevent heart attack and death for millions of patients.
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