Cardiac CTA calls for close collaboration from day one

December 1, 2006
Stephan Achenbach, MD

I have been performing CT angiography of the coronary arteries since 1993, mainly at the University of Erlangen-Nuremberg. Collaboration with radiologists has been good from the start. I know of several other hospitals in Germany where cardiac CTA works similarly well, but I also know of many where it does not. Why the difference?

I have been performing CT angiography of the coronary arteries since 1993, mainly at the University of Erlangen-Nuremberg. Collaboration with radiologists has been good from the start. I know of several other hospitals in Germany where cardiac CTA works similarly well, but I also know of many where it does not. Why the difference?

Turf battles over cardiac CTA have been caused by two main issues. The first is ownership. Put simply, radiologists have the equipment and cardiologists have the patients. Cardiologists may be unwilling to send their patients to radiology for a diagnostic examination. They may have concerns over scan quality, especially if the practitioner is not thoroughly trained in cardiac CT. They may also want to keep the business for themselves, which they can do by performing cardiac catheterization. But cardiologists may not be able to justify buying a high-end CT scanner themselves.

The second issue, relevant in many countries, is the question of who may legally operate a CT scanner. A radiology qualification or CT certification may be necessary. Dedicated licenses-for example, for radiation protection-may be required as well. Cardiologists may have experience in x-ray-based imaging, but their licenses may not include CT.

A third issue is emerging as well. If you reconstruct the data from cardiac CT a little differently, you can also see parts of the lung. Some say that if you can see the lung, then you should check for asymptomatic pathology. This is a reasonable point of view. Of course, cardiologists are not trained to read the lung, so radiologists then say that they should be doing the cardiac CTA because they are better trained to spot these incidental findings.

This matter is unresolved at the moment. It is likely to increase in importance as cardiac CTA enters routine clinical practice. Some debate remains about the need for practitioners to look at the lung when performing a cardiac scan. After all, cardiologists use ultrasound to examine the heart all the time. In theory, if they angled the transducer a little differently, they could see the liver. No one is asking cardiologists to specifically look at the liver during an echocardiography examination.

We have managed to avoid starting a turf war over cardiac CTA at Erlangen. Cardiology and radiology each have their own CT scanners, which eases the ownership problem. Although cardiology paid for its own CT equipment, and the scanner is operated by cardiologists, the license is held by the chief of radiology. If a patient walks into the radiology department and wants a cardiac CT, he or she can get cardiac CT from the radiology department. If the patient walks into the cardiology department, he or she can get that scan from us. If the radiologist looking at the heart has a problem, I can look at the scan too. The radiologists look at the scans with us to analyze incidental findings.

I have observed that the turf war over cardiac CT has died down a bit in many centers over the past few years. Centers setting up programs now are thinking more about the practical and economic aspects and realizing that it is better to collaborate from the beginning. Radiologists and cardiologists now often visit Erlangen together to see how we are using our CT scanner for cardiac work. We are also seeing large cardiology groups that want to buy a scanner themselves and then hire a radiologist.

Any group setting up a cardiac CT program needs to bring cardiologists and radiologists together somehow. Staff should be trained properly from the outset. Radiologists should be willing to learn more about the heart, and cardiologists should be willing to learn about tomographic imaging, contrast, and radiation protection. Attending specialty meetings such as the European Society of Cardiology's annual meeting, the European Congress of Radiology, or dedicated cardiac CT courses is a good way to do this. I don't think it makes a great deal of difference where you start, but you have to be willing to make this investment in learning.

PROF. DR. ACHENBACH is a senior consultant in the department of internal medicine II (cardiology) at the University of Erlangen-Nuremberg in Germany.