Michael Houghton for The New York Times
At the Cleveland Clinic, Thomas Pursch, 75, is prepared for a CT scan. Such machines are poised to change the diagnosis of heart disease.
Posted on 11/16/2004 9:52:19 PM PST by neverdem
What if doctors had a new way to diagnose heart disease that took only seconds and provided pictures so clear it showed every clogged artery, so detailed that it was like holding a living heart in your hand?
In fact, that new way exists and is coming into use in scattered areas of the country, and there is wide agreement that it will revolutionize cardiology.
The scans can largely replace diagnostic angiograms, the expensive, onerous way of looking for blockages in arteries, and can make diagnosis so easy that doctors would not hesitate to use them. They are expected to cost about $700, compared with about $4,000 for an angiogram.
Moreover, the scans take seconds to conduct and require no recuperation time; angiograms take nearly an hour and patients must stay in the hospital for a day. The new scans can see not just the outline of blood vessels but every detail inside and out.
Even so, there is hardly wide agreement over whether this new technique, known as multidetector CT scans of the heart, is entirely a good thing. Indeed, critics say, the technology is ripe for overuse, with doctors scanning people who do not need to be scanned and finding - and fixing - medical problems that do not need to be fixed.
Even within one institution, cardiologists differ.
The scans "will completely revolutionize medicine," said Dr. Mario J. Garcia, director of the echocardiography lab at the Cleveland Clinic. Diagnosis of heart disease, he argued, will be transformed, and lives saved.
Dr. Garcia gave an example: Most people who come to an emergency room with chest pains have a pulled muscle and are not having a heart attack. Yet many are admitted to the hospital and observed for 24 hours.
"That's very expensive," he said. "You have to do blood tests and monitor the heart for a day and maybe do a stress test before they let you go home.'' If the tests look suspicious, the patient is sent for an angiogram.
But, Dr. Garcia said, "this CT machine in an emergency room could take a picture and very quickly tell" whether the pain is from a blocked artery, or not. He added: "That's a phenomenal potential. I am convinced it will change the practice of medicine.''
Dr. Garcia's colleague, Dr. Steven Nissen, head of clinical cardiology at the Cleveland Clinic, has a very different opinion.
"To me, it's a nightmare waiting to happen," said Dr. Nissen, who is calling for strict guidelines overseeing use of the new machines. "I am concerned that it is going to be difficult to control and it could bust the health care system in terms of cost."
It is, medical experts agree, an extraordinary time in cardiology. Depending on which way the scanning market goes, the nation could save a fortune on diagnostic tests, and medical care could be improved. Or expenses could soar and patients could be harmed. The question is, how, if at all, can the technology be controlled?
With the new scans, most patients with chest pains or other symptoms will no longer need angiograms to see if a coronary artery is narrowed or blocked by atherosclerosis.
That procedure typically takes 45 minutes and requires sedating the patient, threading a catheter from the groin to the heart, injecting a dye and taking X-ray pictures that show outlines of the arteries. It is about four times as expensive as the new CT scans are expected to cost.
Excited by the scans' potential, companies including General Electric, Siemens, Philips and Toshiba are competing to make the machines. They say they could save the health care system money by replacing diagnostic angiograms and be lucrative for doctors and hospitals - as well as for the manufacturers.
Hundreds of medical centers have scanners that can show the heart and its arteries, but companies are only now installing their most recently developed machines, ones with as many as 64 detectors, as compared with old machines that had at most four detectors and could not provide clear images of a beating heart.
In a CT scan, X-rays pass through the heart and are picked up by detectors that send information to a computer that constructs an image. The more detectors, the greater the resolution.
G.E., for example, says it will install several of its 64-detector machines in medical centers by the end of the year and several hundred by the end of 2005. The Cleveland Clinic just got a 40-detector machine, made by Philips. Siemens has already installed 20 of its newest machines in the United States, including one at the New York University Medical Center. Mount Sinai Medical Center in Manhattan has several new machines made by different companies, "to encourage competition," said Dr. Valentin Fuster, a cardiologist there.
Yet some heart experts see trouble ahead. For example, the scans identify narrowed coronary arteries in people with no symptoms of heart disease, like chest pains. Once a narrowing is detected, many doctors and most patients want to fix it, inserting a stent or doing bypass surgery - even though research shows such actions will not prevent heart attacks in such patients.
Patients might think such a procedure reasonable, just in case. But "you have a lot to lose," said Dr. Geoffrey Rubin, the chief of cardiovascular imaging at Stanford University Medical Center. "All these procedures are risky," and with no demonstrated benefit, there is no justification for the risk, he said.
For example, putting a catheter in an artery in preparation to insert a stent can accidentally separate layers of the coronary artery. "It can create disease where none existed before," Dr. Rubin said.
"There also is a small but very real risk of stroke when the catheter comes along the aorta, and something can flick off and go to the head," Dr. Rubin said.
The scans also show the lungs, and often reveal little spots, almost all of which are harmless. But once the spots are seen, many patients have extensive testing, even surgery, to find out whether they are cancers.
Even if a cancer is found, patients may not be helped, said Dr. H. Gilbert Welch, an expert on early diagnosis at the Veterans Affairs Medical Center in White River Junction, Vt.
Cancers do not always spread and cause harm; most simply stay small and inconsequential, but no one knows which early cancer is dangerous and which is not. And no one knows whether operating on early cancers saves lives or whether the deadly cancers have already spread by the time they are found.
By incidentally scanning the lungs of symptomless people, Dr. Welch said, doctors will find these small spots, frighten many patients and lead many to have biopsies and other procedures for tiny, harmless lumps. "We can cause more problems than we can solve," Dr. Welch said.
Yet researchers say the new heart scans also hold immense promise.
"This is a technology that has the potential to revolutionize the way we practice cardiology in this country," said Dr. Joao Lima, a cardiovascular imaging specialist at Johns Hopkins University School of Medicine.
Unlike angiograms, scans can show dangerous areas of fatty deposits in arteries that are not blocking blood vessels but that could rupture and cause a heart attack, said Dr. William O'Neill, the corporate director of cardiology at William Beaumont Hospital in Royal Oaks, Mich. That could let doctors scan smokers and middle-aged and elderly people, find those at risk of a heart attack, and treat them with drugs, potentially saving lives.
The scans have some limitations. They cannot penetrate extensive areas of old, calcified plaque, they do not work well when patients are obese or have abnormal heart rhythms, and they use high doses of radiation, similar to the doses used in angiography.
Heart disease researchers say that now is the time, while medical centers evaluate the scanners, to make sure they are used only when they will be truly beneficial. But that may not be so easy.
"It's very, very, very hard to control a technology," said Dr. Mark Hlatky, a professor of health research and policy and of medicine at Stanford University.
The machines cost $1.5 million to $2 million each. But G.E., for one, says the expense is not much more than what it costs to build an angiography suite and argues that the scans can soon pay for themselves.
Four to six patients can be seen an hour, the company notes, compared with one patient an hour getting an angiogram in a coronary catheterization laboratory.
And while the scans are expected to cost less, "the payback to the institution is typically much sooner" with CT than with a coronary catheterization laboratory, said Sholom Ackelsberg, general manager for global CT and functional imaging research at G.E.'s health care division.
It may not be just the institution that collects money, said Dr. Eric Topol, a cardiologist at the Cleveland Clinic. Coronary catheterization is conducted in a hospital, and insurers make one payment, a "facilities fee," to the hospital and another to the cardiologist who does the test.
Cardiologists, radiologists and others could buy their own CT scanners, though, so all the payments could go to them. The customary amount that insurers will eventually pay for CT scans is not yet known, but "obviously, there's a potential for being financially remunerated at a high level," Dr. Topol said.
Radiologists also say they could do the CT scans, assuming much of the business of cardiologists, who had angiography all to themselves.
"Cardiologists made a lot of money with stress tests and coronary catheterization," said Dr. David Dowe, a radiologist who is medical director and chief operating officer of Atlantic Medical Imaging in Galloway, N.J. "Now radiologists are capable of doing this test without a cardiologist's involvement."
Some who have had CT heart scans are delighted.
At Beaumont Hospital, which has a new Siemens scanner, Dr. O'Neill had a scan himself. He has also had an angiogram. With a strong history of heart disease in his family, he wanted to check his arteries, even though he had no symptoms.
"The difference was just amazing," he said of the two scans.
"With the angiogram, I was in the cath lab, lying on the table, unclothed, with a catheter in my groin, and then I had to lie down for eight hours of recuperation.
"With the CT, I went downstairs, they put an I.V. in my arm, I took off my shirt, lay down, and within 15 minutes I was back at work," Dr. O'Neill said. His blood vessels, he added, were fine.
Dr. O'Neill said he too is concerned about overuse. But his experience - having a CT scan though he had no symptoms of heart disease - is exactly what worries doctors who fear it will lead to unneeded treatments.
If scans were used for people at risk for heart disease, almost everyone would be a candidate, Dr. Topol said. About 75 percent of adult Americans have risk factors for heart disease. Most middle-aged people have narrowed areas in their arteries.
"Coronary narrowings are pervasive, endemic in our society," Dr. Topol said.
But even as the scans are being evaluated at major medical centers, doctors in private practice are offering them to patients.
Dr. Dowe, the radiologist, conducts such tests. He said he had done about 1,000, many on people with no symptoms of heart disease but who are at risk. Insurers, including Medicare, pay him $700 a scan for patients with symptoms, he said. As the insurers instructed, he bills for a CT angiogram of the chest.
When Dr. Dowe sees plaque that is growing in the artery wall, a sign of developing heart disease, but no narrowings, he advises medical management for the patient, like cholesterol-lowering drugs or drugs to control blood pressure. The scan can be a real impetus to start a treatment, or stick with one, he said.
Dr. Topol said there was no justification for scanning people at risk of heart disease, but with no symptoms. "I wouldn't have imagined that this could have gone so far already in the wrong direction," he said.
He and others hope that professional medical societies can set guidelines for appropriate use, and insurers can enforce them.
Dr. Nissen wants guidelines, too. "I am vice president of the American College of Cardiology and in 2006 I will be president," he said. "I will press for an appropriateness standard," to guide the use of the scans.
Such guidelines have not stopped overuse in the past, he acknowledged. And, in this case, he said, "I am afraid the genie is already out of the bottle."
Michael Houghton for The New York Times
At the Cleveland Clinic, Thomas Pursch, 75, is prepared for a CT scan. Such machines are poised to change the diagnosis of heart disease.
What are the chances that the good Dr. Nissen has been making a high-dollar living in the cath lab -- doing angiograms...?
Thanks!!!!!!!!!!!!!!!!
I don't know, but it seems damn strange to me that any professional would consider an improved diagnostic tool to be a liability.
"Dr. Steven Nissen, head of clinical cardiology at the Cleveland Clinic, has a very different opinion."
As head of clinical cardiology at the Cleveland Clinic, Dr. Steven Nissen isn't going to the poor house if he does his work at the cath lab pro bono. Third party insurers, the gov't and everbody else with an interest in the cost of medicine better get a handle on it. Lord knows the trial lawyers will. This isn't just a pissing contest between interventional cardiologists and radiologists.
FReepmail me if you want on or off my health and science ping list.
Seems like a 3300 dollar liability to the good doctor complaining........all about the all might buck ya know.
As a Family Practice doctor this sounds wounderful. Much cheaper. Less dangerous. No need to ship patient to another hospital(saves on time and money of ambulance or helo),saves on unnecessary hospitilizations---hence money. Helps to not overtreat patients as unstable angina with some risky medications. Would cut down on the worry of missing a real heart problem us just reflux etc. Sounds wonderful. Yes it would cut down on the income for cardiologists but I don't care. Most are over worked and they will still make big money doing stent placements and other things.
Omigoodness. Although I could handle a test in that CT machine, just seeing it reminds me of an MRI machine and doubles my heart rate. I've been claustrophobic my whole life, but never anything debilitating; just don't try to hold me down or close me in if you don't wanna get hurt. :-)
That was before I was ordered to have an MRI a couple of years ago. I started into that tunnel and FREAKED. Tried five times. Went to another hospital where they had what they called an "open" MRI, but that sucker wasn't open enough. Freaked out there too, and after that, I couldn't sleep right for a month. Everytime I'd lie down I could see and feel that cage coming down over my face and locking down, and the panic would hit all over again.
I've since located the company that makes a truly open MRI, but there's not one anywhere close. Anyone else this severely claustrophobic? Since the MRI experience, I even have trouble flying.
MM
Had my heart scan. ZERO! not only zero overall but zero on ALL subtests! I have a crushed disc in my thorax that causes intermittent chest pain and it bugged me to death when I thought my arteries were clogged solid because my GP was trying to foist the statin of the day on me. What a RELIEF!
Go get one for the peace of mind.
Imagine when a home version is available.
(much like blood pressure machines are now)
THIS is why the United States has the best medical care in the world! Bet you won't be finding any of these machines in Canada!
The radiologists can't put in stents etc. The scans are just another cool diagnostic toy for the cardiologists. They're going to have to deal with the false positives and negatives in real time on real people and make the critical judgement calls.
You're so right. The cath lab is too profitable to give up. I am sure they would be in favor of this if it was more profitable for them.
I have two cardiac stents (which work great!) , and later, a vascular surgeon wanted to do an angiogram of my right carotid to verify what could be seen clearly on the doppler ultrasound. I said, "no, thanks"!
When I told my cardiologist, he said, "You definitely did the right thing; that vascular guy pulls that stunt all the time. He's known for leaving big scars, and we may need access via your RFA if those stents give you any trouble later."
If need be, I'll travel halfway across the nation for one of the new scans, rather than risk an extra angiogram...
They are concerned about the missed cases and law suit.
Angiograms are the gold standard. I can see a lawyer tearing one of these guys up " Why did you use the cheap test rather than the one that has been proved for the past 15 years".
Women and minorities hardest hit.
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