When it comes to identifying and intervening against heart disease, waiting for a patient to present with chest pain is akin to waiting for someone to develop advanced cancer rather than pinpointing it earlier when treatments may be more effective. While waiting for late-stage disease is not an ideal preventive approach, this approach has nevertheless represented the historical standard of heart disease care for decades.

Our approach to heart disease has been ineffective, with a person dying of heart disease every 1.7 seconds, and with more than half of all heart attacks occurring in individuals who experience no symptoms before the catastrophic event takes place. In part, this failure stems from a focus on indirect surrogate markers of heart disease—such as risk factors (e.g., cholesterol, blood pressure, etc.), symptoms and stress tests—rather than simply examining the disease itself. The primary disease process is the atherosclerotic plaque that builds up silently in the walls of the heart arteries over many years.

To improve heart attack prevention, there is an urgent unmet need to modernize our approach from late-stage symptom-driven care to direct disease-based care, a care paradigm that addresses heart attack risk in all patients across the entire continuum of heart disease severity. We can do so by leveraging non-invasive coronary computed tomography angiography (CCTA) – a rapid, safe and accurate approach to evaluation of heart disease. Unlike other evaluation methods, CCTA identifies atherosclerotic plaque buildup in all of the heart arteries and their branches, which has been shown in prior landmark clinical trials to be the strongest predictor of a patient’s likelihood of suffering a heart attack.

In my previous roles as professor of Radiology and Medicine (Cardiology) at the Weill Cornell Medical College and director of the Dalio Institute of Cardiovascular Imaging at the NewYork-Presbyterian Hospital, I spent more than 15 years trying to better understand and integrate the information enabled by CCTA into an approach that could identify individuals at risk of heart attacks and treat them effectively. The results from an array of clinical trials support CCTA as an effective first-line tool for evaluation of patients with suspected heart disease and for some time, CCTA has been recognized as the leading approach to heart disease evaluation in Europe, Japan and Korea.

The recently updated 2021 clinical practice guidelines from the American College of Cardiology (ACC), American Heart Association (AHA) and other United States professional subspecialty societies now espouse CCTA as the first-line test for physicians to better evaluate symptomatic patients with suspected heart disease. With CCTA as the new standard of care, we can now advance the diagnosis process, identify patients earlier and with greater accuracy and precision, and treat cardiovascular disease more effectively to improve our patients’ outcomes.

What AHA/ACC guidelines mean for patients

As part of the AHA/ACC guidelines, CCTA was afforded the highest possible scientific evidence-based designation — Level 1A. This allows CCTA to be used across stable chest pain not only in outpatient settings, but also for acute chest pain in the emergency department. CCTA is the only modality that has met the highest designation through a robust and contemporary scientific evidence base of large-scale multicenter and randomized controlled trials. As the only diagnostic approach to achieve this, it supersedes recommendations for all other testing methods, including historical approaches such as stress testing.

Further, these new clinical practice guidelines represent the first time the AHA/ACC have recommended evaluation of atherosclerotic plaque to assess risk and guide therapeutic decision making across time, as opposed to the traditional speculative methods that employ indirect markers or surrogates of heart disease. The new AHA/ACC clinical practice guidelines emphasize the incomparable value of CCTA for guiding both invasive and medical therapies.

Changing the paradigm of heart disease care 

The use of imaging to guide interventional heart therapies is rooted in a strong body of evidence that demonstrates the effectiveness of this approach to relieve chest pain and improve quality of life. But these same clinical trials have shown a paradigm of imaging-guided invasive therapy to be ineffective at reducing heart attack and prolonging life. As a field, we must uncouple two questions that we have erroneously conflated as one: (1) Are my patient’s symptoms related to heart disease? (2) Is my patient at risk of heart attack and can I treat this effectively with medicines and lifestyle interventions, such as diet and exercise? As the majority of individuals who will suffer heart attacks or sudden coronary death do not, in fact, experience symptoms before their events, the new AHA/ACC guidelines are a major step forward on this path. By prioritizing direct imaging of atherosclerotic disease over more abstract measures, we can fundamentally change the heart disease care paradigm to eradicate heart attacks from the face of the earth. We don’t have a treatment problem as there are an array of medical and lifestyle interventions that can reduce heart attack. We have an identification problem wherein we do not precisely pinpoint those at risk in need of medicines and lifestyle changes.

Undoubtedly, we will see a transition away from stress tests as a first line approach to diagnosing heart disease with a CCTA-based approach. Given the richness of information embedded within any individual’s CCTA study, we also urgently need innovative tools that can take the advanced imaging science and translate it into actionable clinical insights that improve diagnostic certainty for non-imaging clinicians (e.g., primary care physicians, general cardiologists, etc.) and unlock knowledge for patients through improvements in health literacy. Based upon the evidence to date, by targeting each stakeholder in the care paradigm – imaging physicians, treating clinicians and patients – overall costs of care will be significantly reduced, and clinical outcomes improved. Ultimately, this approach can improve workflow, reduce costs, improve literacy and save lives.

Through a CCTA-enabled disease-based approach, early quantification and characterization of heart disease will enable earlier and more effective treatment that can prevent heart attacks and death for millions of patients.

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