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Originally posted by MNSIG:

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Originally posted by sjtill:
Why not just get it done? Lots and lots of errors, both false positives and false negatives, which leads to unnecessary anxiety and unnecessary testing.

Let me tell you about my wife's experience with this test and the way it played out. It's been about 10 years, so I may be off on a few details, but it doesn't really change the overall story.

She went to one of the local Women's Heart Health seminars where they watched some lectures, did bloodwork and got a calcium scan for a few hundred dollars. She was about 40 at the time and without symptoms. This was done at the cardiac care center at the local hospital.

1. Scan was negative for calcium- Great

2. About a week later, she got a call from her doctor saying that the radiologist that read the scan (a few days after the seminar) agreed that the arteries were fine, BUT noticed something abnormal on one lung. Well, can't just let that go.

3. CT scan of the lung in question- inconclusive. Can't leave it at that and risk malpractice

4. Contrast CT of lung which identified a benign vascular malformation. No need to do anything with that, BUT....

5. This CT was high enough to reveal a couple of small nodules on her thyroid. Need an ultrasound to check those out.

6. Ultrasound showed them to be quite small, 4mm so just watch for now with annual ultrasounds. "Just for peace of mind".

7. Not much change until about the 4th year at which point one of the nodules hit the magic 5mm threshold for biopsy.

6. Ultrasound guided needle biopsy inconclusive, on one of the two

7. Back a few weeks later for another one- This one showed some abnormal cells. Can't have that. Better have half your thyroid removed. You know. "Just for peace of mind"

8. Thyroid surgery and subsequent pathology found a 4mm nodule (smaller than ultrasound indicated) with some neoplastic cells. So, technically she did have a tiny spot of thyroid cancer, but it is unlikely it would have EVER caused her a problem.

Bottom line: 5-6 years of annual testing, hospitalization and surgery, about $15,000 in out of pocket expenses, plus what ever insurance paid and now a lifetime of thyroid hormone replacement.

For what? "Just for peace of mind"

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Originally posted by sjtill:

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sjtill, I am curious if you are familiar with FFRct, marketed by HeartFlow.

I’m familiar with fractional flow reserve as used in conventional coronary angiography to determine severity of stenosis. Looks like this applies that function to images from a coronary CT angiogram (not the same as calcium score CT), to make it more accurate. Potentially useful, but not as screening test as high dose of radiation involved.

By the way: the reason for doing screening tests is to find disease that needs to be treated to prevent a worse outcome than would occur if you wait for symptoms.
The minority of people have disease such as left main coronary disease that will benefit from “revascularization”, that is improving flow through the arteries by surgery or stenting.
A lot of the intervention (stenting) done in the past on asymptomatic patients has now been shown not to prolong life.
That’s been a really hard thing for cardiologists and surgeons to accept, because we thought it was “obvious” that opening up those arteries would decrease the risk of death, compared with medical treatment (aspiring, statins, ACE inhibitors, BP control).

Here’s the relevant recommendations from UpToDate on this issue:

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SUMMARY AND RECOMMENDATIONS

●We recommend coronary artery revascularization for two groups of patients with stable angina (Grade 1A) (see 'Improvement in survival' above):
•Patients in whom maximal medical therapy has not satisfactorily improved anginal symptoms or who are intolerant of medical therapy. (See 'Relief of angina' above.)
•Patients with high-risk criteria and selected patients with intermediate-risk criteria on noninvasive testing, regardless of anginal severity. (See 'Improvement in survival' above and 'Severity of coronary artery disease' above.)
●For patients with stable angina that is not significantly interfering with the quality of life, and for whom revascularization is not indicated to prolong life, we suggest initial medical therapy rather than immediate revascularization (Grade 2B). In such patients, patient preference may be important. (See 'Patient preference' above and 'Indications for PCI' above.)
Similarly, after a period of medical therapy, percutaneous coronary intervention (PCI) may be a reasonable option for patients who prefer to avoid the possibility of urgent revascularization.
●Coronary artery bypass graft surgery is preferred to PCI for many patients in whom a survival benefit from revascularization has been demonstrated, such as those with left main coronary artery disease. (See 'CABG versus PCI' above.)

As a result of these recent studies, there is a turn toward bypass surgery in diabetics and patients with left main disease, rather than the less-invasive stenting.

Yes, the technology is changing, but we need a solid base of scientific evidence, and new technology must be rigorously shown to be superior to the old in improving survival or reducing symptoms before it should be adopted.

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I have seen several of these novel approaches marketed as replacements for invasive procedures.....not many have panned out.

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Originally posted by sjtill:

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I have seen several of these novel approaches marketed as replacements for invasive procedures.....not many have panned out.

There's a huge amount of money to be made doing cardiac procedures--for many if not most hospitals the cath lab and cardiac surgery are cash cows.

There has been enormous technical progress, but more new technologies have been left behind than have made the grade.

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posted April 10, 2019 02:56 PM Hide Post
quote:
Originally posted by sjtill:
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I have seen several of these novel approaches marketed as replacements for invasive procedures.....not many have panned out.


There's a huge amount of money to be made doing cardiac procedures--for many if not most hospitals the cath lab and cardiac surgery are cash cows.

There has been enormous technical progress, but more new technologies have been left behind than have made the grade.



A high percentage of diagnostic caths result in no intervention. I see HeartFlow targeting private payers and CMS just for this reason, to replace these diagnostic caths with the lower cost CT and FFRct analysis. If they can successfully position this test between the MUGA or stress echo and a cath as a secondary screen they stand to make a lot of money while the hospitals and cardiologist stand to lose a lot from lost procedure volume. Should be interesting to see it play out over the next year or two.

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Originally posted by ZSMICHAEL:

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posted April 10, 2019 02:56 PM Hide Post
quote:
Originally posted by sjtill:
quote:
I have seen several of these novel approaches marketed as replacements for invasive procedures.....not many have panned out.


There's a huge amount of money to be made doing cardiac procedures--for many if not most hospitals the cath lab and cardiac surgery are cash cows.

There has been enormous technical progress, but more new technologies have been left behind than have made the grade.



A high percentage of diagnostic caths result in no intervention. I see HeartFlow targeting private payers and CMS just for this reason, to replace these diagnostic caths with the lower cost CT and FFRct analysis. If they can successfully position this test between the MUGA or stress echo and a cath as a secondary screen they stand to make a lot of money while the hospitals and cardiologist stand to lose a lot from lost procedure volume. Should be interesting to see it play out over the next year or two.

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
This is one reason that I despise the business of health care. I know it is here to stay. Somehow it should be different than figuring out how to maximize profit and corner the market.

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Originally posted by TXJIM:
Its a conundrum, profit motive (Capitalism), drives innovation by some and motivates others to protect the status quo. The rub comes when a new technology stands to eliminate a huge profit center for the providers. As a patient I would much rather have a 5 minute CT scan than be sedated and have a wire run from my crotch to my heart, be injected with contrast and radiated to boot. My insurance company would love to save thousands too.

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Originally posted by MNSIG:

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Originally posted by TXJIM:
Its a conundrum, profit motive (Capitalism), drives innovation by some and motivates others to protect the status quo. The rub comes when a new technology stands to eliminate a huge profit center for the providers. As a patient I would much rather have a 5 minute CT scan than be sedated and have a wire run from my crotch to my heart, be injected with contrast and radiated to boot. My insurance company would love to save thousands too.

I don't think there are many cardiologists advocating angiograms for asymptomatic patients. I do agree with you in general, though. There is absolutely no doubt in my mind that colonoscopies are the "gold standard" for colon cancer detection because they haul in the real gold for clinics.

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I believe that a TEE, Trans Esophageal Echocardiogram, will reveal any significant calcium/plaque buildup in the heart; especially on the valves.
Cardiologists, please correct me if erroneous.

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Originally posted by TXJIM:
Colonoscopy is a great example, I almost cited it earlier. CT virtual colonoscopy was going to cut colonoscopies in half 10 years ago. Providers argued that they are likely to take samples for pathology in enough cases that it was better to just scope patients and save the radiation. Providers won and virtual colonoscopy was a financial flop.