Health Imaging & IT - October 2007 - (Page 42) special section: Inside Cardiac Imaging Free breathing, whole heart magnetic resonance coronary angiography images from the Toshiba America Medical Systems Vantage depict the right coronary, left anterior descending and left circumflex arteries. Images were post processed on the Virtual Explorer workstation. document coronary disease, treat it medically and cath them later if necessary.” mr knowledge needed Cardiac MR also is growing, but the biggest obstacle is the small number of locations where clinicians can train, says Tony Fuisz, MD, cardiologist at Washington Hospital Center in Washington, D.C. Fuisz uses the MR suite from Philips Medical Systems as well as 1.5T and 3T scanners from Philips. “A certain amount of technical background and knowledge is needed to perform these studies well but the number of places to learn is small,” he says. To address the problem, the American College of Radiology is ensuring a radiology presence in cardiac MR by including the modality on the exams given to graduating radiology residents. On the cardiology side, there is an effort underway to include cardiac MR in training programs. Despite these efforts, the modality “almost always requires someone to invest more time to learn.” Cardiac MR has taken a lesson from CT, which offers one-button studies, says Fuisz. “Cardiac MR has gotten significantly simpler in the last 10 years.” Once learned, the modality is good for a wide range of patients who are potential candidates. “In any given day, we might go from a patient with a complex congenital heart problem to a patient with chest pain and enzyme rise and might diagnosis a myocardial infarction.” The wide range of applications separates cardiac MR from cardiac CT. Fuisz says that the focus in cardiology is moving away from treating patients with catheters and other invasive procedures and toward earlier diagnosis of problems—at a point where they can be effectively treated with pharmaceuticals. lot of rapid growth,” Stillman says. More research on outcomes should help push payors along, he says. The technology is good for two large groups of patients: acute and chronic. “Most people don’t see this as a screening test for the worried well,” he says. “It probably isn’t worth the cost or even the radiation risk. But for someone with chest pain, it really changes the dynamics.” managing chest pain Stillman says there is a lot of interest right now in acute chest pain. Patients with no changes seen in an electrocardiogram and unchanged enzymes make the cause of their chest pain unclear. “Oftentimes, these patients are admitted, they have multiple tests and are ultimately sent home because they don’t have a cardiac cause for chest pain. It’s very costly to do all of that.” Coronary CT angiography’s high negative predictive value makes it safe to send these patients home and several studies have demonstrated that. Those with chronic chest pain are a much larger group. Up to 85 percent of patients at the typical cardiac cath lab don’t have acute chest pain. The COURAGE study, published earlier this year in The New England Journal of Medicine, found that the use of drug therapy is just as effective in preventing heart attacks or death when compared to a combination of drug therapy and stent implantation. “Those patients who had their angiography and stents could have been equally well treated medically at a substantial cost savings. You can argue that you can just 42 O C T O B E R 2 0 07 | Health Imaging & IT A novel technique Timothy Albert, MD, director of cardiovascular imaging center at Ryan Ranch in Salinas Valley Hospital, Salinas, Calif., and assistant consulting professor of medicine at Duke University, looks at utilization of cardiac MR. “For cardiologists, it’s a very novel technique,” he says. He has worked to simplify it, define protocols and make the uses clear. Albert has been working with Toshiba America Medical Systems for about a year and uses the company’s Aquilion 64-slice scanner and Vantage MR system powered by Atlas. He did an advanced fellowship at Duke University at their cardiovascular MR center and then started the cardiovascular imaging center in Salinas. He now works with both Toshiba and Duke in a joint research relationship. “Even amongst physicians, there is deep confusion between CT and MR. I look at them as being synergistic tools,” he says. There is a lot of overlap but they also have unique strengths they bring to cardiovascular patients. MR is used extensively for cardiac valve assessment, heart structure assessment, scar from prior heart attacks, and diagnosis of a previous heart attack. “We are finding that more and more patients have silent myocardial infarctions (MIs),” Albert says. A recent study showed that about 20 percent of people over 70 have had a silent MI and the only way to definitively diagnosis that is with MR. Albert also is working on setting up stress MR/perfusion testing. “MR is the newest tool for stress testing,” he says, because it allows for viewing of structure and function and higher resolution images of blood flow to the heart. Physicians struggle with how MR fits into their practice, says Albert. “MR has so many different applications and affects so many different tests we already do. It’s hard to pin it to one category.” MR, however, has the benefit of having well-established and universally accepted billing codes. “MR is maybe a little harder to apply in practice but the billing isn’t as unknown.” (continued on page 44) HealthImaging.com http://HealthImaging.com
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