No Evidence for CT Angiogram

News about the popular CT angiogram has been strewn about the medical headlines recently [Source: WebMD, NYTimes]. This technology is billed as a way to determine coronary artery disease in those without any symptoms. The problem: There is absolutely no evidence to support this. So what do you get for your money? Some fancy pictures, and according to The New York Times, the privilege of helping your cardiologist pay for his new Hummer. Concerned?

The CT angiogram is a high-resolution CT (computed tomography) scan that is capable of taking incredible still pictures of a beating heart. Using nuclear medicine, injected into the bloodstream, the coronary arteries can be viewed in great detail, theoretically determining the level of blockage in the arteries.

At this point, CT angiography appears to be generating more harm than good. The 1-in-200 risk of developing cancer from the radiation dose is very real, while the chance that this will have any clinical ability to help someone who is not having symptoms of cardiac disease is not. The problem with this technology and its usefulness is that the 90-percent blockages detected on these scans are not the ones that kill people; it’s the 30-percent blockages. Chances are the body has already made new blood vessels to bypass the bigger blockages, so they pose little risk. The unstable, smaller plaques are the ones that rupture, causing an immediate blockage in a coronary artery resulting in a myocardial infarction (heart attack).

According to the article, it's a proven fact that a physician with a financial interest in any test, or who stands to gain some compensation for using it, will order it more often than a physician without any. The same holds true for labs. If a physician stands to profit from labs performed on their patients, they order more labs. So they market these fancy images and high technology to patients fearful of the nation’s No. 1 killer and take it right to the bank. I don’t have a problem with a patient who is willing to pay out of pocket for such technology, given they understand the poor clinical value of such fancy images and the increased cancer risk. The issue is that a lot of the money these cardiologists are making (up to 50 percent of their $400,000 income) comes from Medicare and other insurance carriers.

So how do cardiologists get by raking in money for a test that has no proven value in a country with a true health care crisis (spending twice the average of other countries and overwhelmingly less healthy)? Drumroll please…our government! According to the article, when Medicare threatened to stop payment for the test until proper evidence in its favor was established, cardiologists with The Society of Cardiovascular Computed

Tomography lobbied until the government urged Medicare to back down, which they did. The statement by the SCCT president was, “This decision (stopping payment by Medicare), could essentially put them (SCCT) out of business.” What about the people that now have an increased risk for cancer and whose test offered them no proven benefit? Any concern for them?

Now, I don't want to say this test has aboslutely no benefit. As mentioned in the article, a patient in the ER with chest pain could have the test run to determine very quickly whether this is due to cardiac reasons or another culprit. Sparing an in-patient stay or additional tests is sensible and a good way to promote overall cost savings.

So you have a concern about your heart. What can you do? In this country, it is best to assume that unless you are focusing on sound nutrition, regular physical exercise and stress management you are actively growing plague in your arteries. Start there. Then work with a health care provider to further determine your risk by having a regular checkup along with a fasting cholesterol, a C-reactive protein test and any other recommended testing done. Save that $500-$1,500 dollars a CT angiogram would run you and put it toward organic produce, a gym membership and good quality fish oil supplements.

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Sources

  • http://www.webmd.com/heart-disease/news/20080722/heart-imaging-tool-under-the-microscope
  • http://www.nytimes.com/2008/06/29/business/29scan.html?_r=1&oref=slogin