Incidentally...the Perils and Pitfalls of Cardiac CT

I've just finished reading a very insightful paper in JACC, also covered on heartwire (

It describes a single centre Canadian experience of performing cardiac CT in over 950 patients. All images were reported by experienced radiologists and they calculated the number of non-cardiac incidental findings (IFs) that were thrown up on cardiac CT. Moreover, also included were analyses of the extra cost of investigating the IFs, along with extra attributable radiation exposure. The investigators also provided some follow-up data out to an average of 18 months.

Although incidental findings in this middle-aged group were very common (41.5% of all patients), the striking thing is that almost all of them were of no clinical significance (98.8%). The majority of the non-cardiac findings were in the lungs - pulmonary nodules and emphysematous changes led the list. Investigation of findings of indeterminate significance was costly and potentially hazardous to both patients and healthcare providers.

Further reassurance was provided by the follow-up data. There was no difference in mortality between the patients with IFs and those without, including cancer deaths.

As cardiologists, how do you deal with reading the non-cardiac portion of the CT scan?

Should all studies be reported by radiologists? Should all studies be jointly reported by both a cardiologist and a radiologist?

One other option, suggested in the accompanying editorial, is to let the patient decide, after informed consent whether they would like the non-cardiac structures evaluated or not. Is this a cop out, or is this the only way to truly act in the patient's best interests?

The issues are complex and cross into medical ethics and best practice. It it is already known that screen for lung cancer by CT is not effective. Why then should we report on lung nodules just because they are there?

Please let us know your opinion in the comments and also add your vote to the poll.