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KCE reports 82 C Multislice CT in Coronary Heart Disease vi CONCLUSIONS TECHNICAL EFFICACY 64-SCT has shown to provide images of native coronary arteries with acceptable quality in selected patient populations. In order to obtain high-quality MSCT images, patients should be in a stable sinus rhythm, they shoud be not too obese, they should be able to cooperate and they should have noncalcified coronary arteries. The high burden of ionizing radiation induced by MSCT remains a major obstacle. It is currently not clear whether future technical improvements will lead to less radiation yet preserve adequate diagnostic performance. DIAGNOSTIC ACCURACY The diagnostic accuracy of MSCT in CAD has been thoroughly tested predominantly in patients at high-risk in whom it had already been decided to proceed to CCA. In these populations it is almost as good as CCA in terms of detecting true positives. It performs less well in detecting true negatives, potentially giving rise to a substantial number of false positives. The external validity of the results obtained from clinical trials remains uncertain. DIAGNOSTIC THINKING Only limited data are available supporting the use of MSCT with regard to its role within patient care algorithms. The test performs best in patients with normal coronary arteries, but it has yet to be ascertained whether these (normal) patients could not have been identified noninvasively in a safer and more cost-effective way. THERAPEUTIC IMPACT If MSCT performs in real world as good as in clinical trials, it can be considered a useful test to exclude significant CAD. Documenting obstructive CAD by MSCT is of rather limited value, because patient management and prognosis depend on the functional impact of the coronary stenosis which cannot be assessed by MSCT alone. Moreover, in case revascularisation is deemed appropriate, invasive CCA is inevitable. PATIENT OUTCOMES There is limited data on the prognostic value of MSCT and there is no evidence whatsoever that the use of MSCT improves quality of life, prevents heart attacks or saves lives. COST-EFFECTIVENESS Because data on the clinical effectiveness of MSCT in preventing morbidity and mortality are not available, it is yet impossible to conclude whether it is cost-effective compared to the standard diagnostic protocols in low to intermediate pre-test likelihood patients.
vii Multislice CT in Coronary Heart Disease KCE Reports 82 C RECOMMENDATIONS Evidence is lacking on the clinical and cost effectiveness of MSCT as compared to other diagnostic tests in the diagnosis of CAD in real world populations. However, the technology is already widely diffused throughout the country and at least 20 hospitals are currently performing MSCT angiographies of the coronary arteries, while many others are contemplating starting it up. Moreover a budget of 1 260 000 € has been provided by the government for this diagnostic test for the year 2008. In order to guide ordering of MSCT towards the most promising indications, to prevent inappropriate diffusion of the technology, and to enable making use of prescription data obtained from future examinations, the following reimbursement strategies could be contemplated: Formulate a reimbursement code specifically related to MSCT of the coronary arteries, incorporating restriction rules: 1. Towards patiens: MSCT coronary angiography should be restricted to patients with atypical chest pain in whom other non-invasive diagnostic modalities are not feasible or are inconclusive. Patients with an Agatston score above 400 should not be subjected to an MSCT imaging study. The test should not be used for asymptomatic patients or for screening purposes. 2. Towards physicians: radiologists performing MSCT of the coronary arteries should receive a dedicated training in the technique. Ordering MSCT of the coronary arteries should be restricted to cardiologists or to the future emergency internists. 3. Because results from outcomes trials are not available, it should be contemplated to link the reimbursement of MSCT angiography to the enrollment of patients in such a national randomised outcome trial, financed by the RIZIV/INAMI. At least, a formal registry of patients studied by MSCT, including clinical and follow-up data, should be kept available for peer review. It could be organised by Belgian professional organisations, and audited by the RIZIV/INAMI.
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KCE reports 33 Effects and costs of
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