Cardiovascular imaging research at the crossroads

Cardiovascular (CV) imaging plays a critical role in therapeutic decision making and is performed in more than 10 million patients each year; a large share of the nearly 40 million patients living with CV disease. CV imaging may serve as a valuable component of a patient's evaluation, provided that its enhanced diagnostic findings invoke appropriate and targeted therapies that improve symptom burden and long-term outcomes and are not offset by the upfront procedural and induced costs of care. As well, the overall clinical benefit that imaging imparts to the patient must significantly outweigh any untoward risk, including radiation or procedural complications. Explosive growth in imaging has resulted in a rapid escalation of costs for testing encumbering an estimated $80 billion dollars annually and represents a sizeable portion of cardiologists' income. Concern remains that continued expansion of CV imaging services may further add to the complexity of health care services and magnify the societal burden of health care. The field of CV imaging is beset by high procedural use, high growth rates, and often, a lack of demonstrable quality. The end result of our current health care system and reimbursement models is an over emphasis on volume and throughput, extensive efforts necessary for justification of procedural use, and a broad referral population exceeding guideline-accepted best practices. An inextricable link between imaging markers and outcomes forms a critical nexus that can be used to establish the value of a test, and is now the standard upon which technology will be evaluated by private payers and governmental agencies alike. This new benchmark necessitates high-quality research to compare the effectiveness of CV imaging modalities to elicit improvements in health outcomes; representing a dramatic paradigm shift for the field of CV imaging research. In this review, we will discuss current health policy of CV imaging as well as the future of CV imaging-based comparative effectiveness research.