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This section of Business Briefing: US Cardiology 2006 outlines the significant recent advances that have been made in cardiac imaging. Image detail continues to improve at a rapid pace, as does our ability to detect the physiologic alterations of disease. While many of the tests are complimentary, they are, to some degree, in direct competition with each other. The technologies may also be disruptive in that they may, historically, have been controlled by different medical specialties. For example, computed tomography (CT) has largely been under the control of radiologists. As coronary CT angiography (CTA) gains acceptance as a means to detect stenoses, it can be expected to compete with stress nuclear studies and echocardiography, which have largely been the domain of cardiologists.

Significant turf issues have emerged in the past year because of this perceived threat. Moreover, the imaging science has advanced more quickly than the population studies justifying their use. We are seeing indications of increasing use of CTA without the groundwork to justify its use in special patient populations. There is a sense that the images are so beautiful and lifelike that there is no need for the science behind it. This is, of course, a treacherous road to follow.

Critical in all of this is the development of criteria to guide clinicians in ordering the right test for the right patient at the right time. There are few comparative studies and little in the way of guidelines or consensus statements.

It is possible that the freedom to order these tests will be taken out of our hands. National health expenditures total about US$1.1 trillion dollars and represent nearly 14% of the gross domestic product in the US. US$300 billion of the annual healthcare expenditures go to the assessment and care of ischemic heart disease. Clearly, this is an area large enough to be more than a blip on the radar screen as there are attempts to reign in the ever-escalating healthcare costs. Cost effectiveness studies for critical imaging pathways that incorporate economic and patient outcome measures are desperately needed. Rather than building better mousetraps, I think we now need to steer our attention toward determining how to catch the most mice for the least money.

As you read through this cardiac imaging section, I encourage you to think critically of how these imaging tests may fit into clinical practice. Think also in terms of more global socioeconomic issues. The collision of technology with these issues offers a lot of food for thought and is ripe for research.