New American College of Cardiology/American Heart Association (ACC/AHA) guidance strongly recommends coronary computed tomography (CT) imaging as a noninvasive, first-line tool for evaluating patients with stable chest pain suspected of having possible coronary artery disease (CAD).

The new guideline cites high-quality evidence in concluding coronary CT angiography (CCTA) is “effective for diagnosis of CAD, risk stratification and guiding treatment decisions,” adding that CCTA is appropriate after inconclusive functional tests, such as nuclear and echo stress test echocardiograms, when considering revascularization strategies.

The ACC/AHA guideline also states that CCTA is a definitive test to rule out the possibility of CAD, with 98% negative predictive value.

The Guideline for the Evaluation and Diagnosis of Chest Pain was updated by ACC/AHA in the fourth quarter of 2021, based on five years of data. This was the first significant change in recommendations for evaluation of stable chest pain in 20 years.

Currently, CCTA is the only noninvasive test to receive a Class 1A ACC/AHA recommendation as the initial diagnostic strategy, giving physicians an accurate, rapid test to determine the presence of plaque burden without an invasive procedure.

CT-fractional flow reserve (CT-FFR) is used with the powerful HeartFlow algorithm to give a detailed, color-coded, 3D image of the arteries leading to the heart. CT-FFR shows if there is a narrowing of the arteries and whether blood flow is affected.

The detail provided by CT-FFR previously was available only from cardiac catheterization techniques during a coronary angiogram. Angiograms are still the right option for many patients, but CT-FFR using HeartFlow technology allows many patients to have accurate imaging without an invasive procedure, giving clinicians the information they need to effectively manage patients with stable chest pain.

For patients with stable chest pain and suspected coronary artery disease, the ACC/AHA guidelines say CT-FFR “can be useful for diagnosis of vessel specific ischemia and to guide decision-making regarding the use of coronary revascularization” in stenosis of 40% to 90%.

For patients with stable chest pain and known nonobstructive CAD, CT-FFR can be useful for diagnosis of vesse (lesion)-specific ischemia and for estimating risk of major adverse cardiac events, according to the guidelines.

For some patients, stress testing may still be the best test.

Norton Heart & Vascular Institute leads adoption of CT-FFR

Norton Heart & Vascular Institute was the first in Louisville to offer this advanced imaging analysis to patients. Norton Heart & Vascular Institute has been offering CCT-A since the mid 2000’s as an advanced cardiac imaging option. In April 2020, nearly 18 months ahead of the ACC/AHA guideline changes, the institute began utilizing CT-A with CT-FFR if needed as a first-line tool for evaluating patients of suspected CAD. As early adopters of this technology, the institute’s providers also have been involved in research studies of CT-FFR.

Our team has developed expertise in this advanced technology through our clinical experience and research. Norton Heart & Vascular Institute is recognized by HeartFlow as a platinum site, one of eight health care systems in the country that educate other systems on implementing CT-FFR.

Norton Heart & Vascular Institute has been invited to participate in research that could inform future updates to the guidelines for coronary artery disease. The institute contributed to the Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE trial) looking at the comparative effectiveness of diagnostic evaluation strategies for stable CAD.

Norton Healthcare also is currently one of 15 sites in the United States and Japan participating in the REVEALPLAQUE study, which is collecting data from approximately 250 patients that could impact future updates in guidelines for coronary artery disease. The primary endpoint of the REVEALPLAQUE study is the level of agreement across total plaque volume and the characteristics of plaque as measured by the HeartFlow plaque technology compared with intravascular ultrasound imaging, which is the current standard for obtaining information about plaque burden.