The American Heart Hospital Journal


cardiologists have now left independent private practices and are now employed by hospitals. A related shift of imaging services to the institutional setting is underway. More successful healthcare organizations will preserve the outpatient-friendly service and high quality found in the best private practices, but also promote efficient use of expensive equipment and personnel, fund costly electronic, integrated medical records, electronic reporting, telemedicine, and picture archiving and communication systems (PACS), and institute sophisticated quality assessment and continuous quality improvement programs that can be difficult to implement in small, independent laboratories and physician offices. The danger is that management systems in many hospitals are not geared to delivering convenient, high quality, efficient outpatient care and imaging services. Patient satisfaction and personal service are likely to suffer as budget cuts force ever more drastic consolidation and efficiency measures. These pressures will only increase over the next five years. Regardless of the outcome of the current political battle over healthcare reform, imaging will be a focus for reducing costs.


Although we hold that none of our predictions of five years ago were entirely wrong, several of our predictions will require some modification as we look toward the next five years. Cardiac MR remains a promising modality, with many exciting applications in the cardiomyopathies and complex congenital heart disease. However, its complexity and expense are likely to continue to restrict its use to large referral centers, and its penetration to community-based healthcare will be limited. Similarly, we predict that advanced positron emission tomography (PET), PET-CT and molecular imaging will continue to develop, but with modest penetration at the community hospital level.


Echocardiography (echo) remains at the ‘heart’ of cardiology. Accreditation of laboratories and credentialing of physicians and technologists has perhaps its greatest impact here because variability in image quality can be high for this nearly ubiquitous procedure. Use of ultrasound contrast improves image quality, particularly with stress echo, and we predict that its use will continue to grow. Amazingly inexpensive and technically sophisticated handheld devices are now available that can easily be used at the bedside in a manner similar to the stethoscope. We predict that some hardy cardiologists will continue to venture out of their digital lairs to lay hands on their patients over the next five years. These bedside ‘personal’ echo machines may get greater use if we move away from a fee-for-service model to more bundled care model, in which there will be less concern for


Summer 2011


Five Years On Imaging


documenting each individual component of service to bill and receive additional payment. How bundled payment will affect new and developing echo technologies such as speckle tracking and 3D echo is difficult to predict, but it is safe to say that evidence of efficacy and proof of impact on outcomes will be emphasized for these as for all imaging procedures.


Our predictions of five years ago were perhaps least accurate regarding coronary CT angiography (CTA). Nuclear and echo stress testing still dominate the evaluation of patients with chest pain of uncertain but potentially cardiac etiology. This may change with the publication of additional trials showing that CTA is more rapid, less expensive, and more definitive than stress nuclear or stress echo in identifying patients with normal coronary arteries. We predict that coronary CTA use in the emergency setting will increase over the next five years, particularly as the newer technology allows a lower radiation dose to be used, even when image acquisition protocols are used to simultaneously detect not only coronary disease but also to diagnose aortic dissection and pulmonary embolism. Further development of low radiation CT methods for assessment of myocardial perfusion, atherosclerotic plaque characteristics, and cardiac gross anatomy, as well as coronary angiography, may threaten both cardiac MRI and diagnostic catheter angiography.


Single-photon emission computed tomography (SPECT) stress testing has proved remarkably resilient, in part because it has enjoyed a good track record over many years. The Clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial in particular showed that an overemphasis on coronary anatomy is less useful than an approach that couples coronary anatomy with function, assessing the degree of ischemic burden using nuclear stress testing or other techniques. It is now common to measure fractional flow reserve in the catheterization laboratory in conjunction with coronary angiography when the degree of functional stenosis is uncertain. Functional assessment of ischemia can be obtained using other imaging modalities, including stress echo, stress MRI, PET, and even CTA, but SPECT is robust and has proven effective, and there are a lot of SPECT cameras in use, and not so many stress MR and PET facilities. In the coming years, greater emphasis will be placed on methods that efficiently and accurately demonstrate ischemic burden and its response to treatment, be it surgical, interventional, or pharmacologic. We may see similar imaging advancements in assessing the morphology and functional state of atherosclerotic plaque and its response to therapy, using a variety of unique technologies.


Cardiovascular Imaging—Reflecting on 2006 Predictions and New Predictions for 2016 9


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