Ron Blankstein, MD, MSCCT, associate director, cardiovascular imaging program, director, cardiac computed tomography, Brigham and Women's Hospital, and professor of medicine, Harvard Medical School, was a co-author on the ACC 2021 Chest Pain Guidelines,[1] which now lists coronary computed tomography angiography (CCTA or CTA) as a 1A level recommendation for front line imaging. He gave an overview of the guidelines during the 2022 Society of Cardiovascular Computed Tomography (SCCT) meeting in July. 

"In particular, coronary CTA would be useful in patients who do not have known coronary disease who have an intermediate to high pre-test probability of having obstructive disease," Blankstein explained 

He said there are many tests with a 1A recommendation, and cardiac CT is not always going to be the right test for everyone. But, factors that favor use of CCTA include:    • Younger patients who are not on preventive therapies    • Individuals where the objective of testing is to identify non-obstructive or obstructive coronary artery disease    • This includes scanning patients where there was a previously inconclusive stress test

The guidelines also put a new emphasis on non-obstructive coronary artery disease.

"This guideline is the first time ever that non-obstructiuve CAD is now classified as coronary disease, and there is a Class 1 to optimize preventive therapies for those patients," Blankstein said. "Coronary CT gives us an opportunity to identify non-obstructive disease, which we might not identify on other types of stress test imaging."

In acute chest pain, coronary CT has a Class 1 indication to rule out disease. But, for patients who already have been diagnosed with coronary disease, there is no need for coronary CTA. Blankstein said this is especially useful in patients who are at intermediate risk for coronary disease.  

CTA also can be used as a gatekeeper for which patients get sent for diagnostic angiography imaging in the cath lab. 

"In the new guidelines, particularly for patients with stable chest pain, there is no longer a category of patients who should go directly to invasive angiography," he said. "The use of imaging in general, including coronary CTA, should always be done, and this is why those intermediate- and high-risk patients are both grouped as a single group when we are deciding whether to do further testing."   With the elevation of CCTA to a 1A recommendation, there has been a lot more interest in cardiac CT since late last fall when the guidelines were released. This was evident at the American College of Cardiology (ACC) 2022 meeting this past spring and with higher engagement than past years with vendors at SCCT.

"I think there are a lot of hospitals that are looking to invest more in coronary CT, and it does take a lot of investment," Blankstein said. "We are seeing increased interest in coronary CTA, and frankly we say that even before the guidelines, but the guidelines will likely fuel that even more."

He said hospitals making the investment need to ensure that they have the right equipment, and the right people in terms or radiologists or cardiologists who can read the studies. 

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1. Martha Gulati, Phillip D. Levy, Debabrata Mukherjee, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov, 78 (22) e187–e285.

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Brian Ghoshhajra, MD, division chief, cardiovascular imaging, Massachusetts General Hospital, explains what specialized training is needed to perform coronary computed tomography angiography (CCTA) as interest rapidly rises in this field. 

Brian Ghoshhajra, MD, MBA, division chief, cardiovascular imaging, Massachusetts General Hospital and associate professor of radiology, Harvard Medical School, and a board member of the Society of cardiovascular Computed Tomography (SCCT), explains the rapidly expanding interest in cardiac computed tomography (CT) under the new chest pain evaluation guidelines.