“#46: Chest pain, coronary CT angiography, and coronary artery disease” – Help From The Curbsiders

The Curbsiders Internal Medicine Podcast series is outstanding.

Today, I’ve reviewed #46: Chest pain, coronary CT angiography, and coronary artery disease JULY 3, 2017 By MATTHEW WATTO, MD.

Here is the Podcast:

Here are excerpts from the show notes:

Coronary CT angiogram is a fabulous test in patients who do not have known coronary artery disease.

Case: 45 yo F active duty Colonel with chronic chest pain syndrome despite negative conventional stress test and CAC score of zero.

The patient had a calcium score of zero and normal stress testing. Her symptoms were that she felt more fatigued than usual with exertion.

So the doctors went ahead and ordered a CT coronary angiogram and she was found to have a very high grade stenosis in her right proximal artery. And she ended up having a procedure based on her refractory symptoms.

And this patient[the patient above], by risk scoring is very low risk. And yet she had obstructive coronary artery disease.

A negative CCTA is wonderful news for the patient.

[And] Your risk is so low with a normal CCTA. . .

This negative [CCTA] test “derisks” you.

The coronary artery calcium score is best for asymptomatic patients – do they need a statin, aspirin, etc to prevent progression of plaque formation.

In symptomatic patients, a calcium score does very well but it is not perfect [See Case Vignette above].

Patients with a calcium score of zero can still have obstructive coronary artery disease, although the risk is very small.

So if a patient with a calcium score of zero is having possible cardiovascular symptoms we need to look further (again see the Case Vignette above).

The various test that we might choose in the patient with possible CV symptoms are very well described (strengths and weaknesses) are well described in the 15 clinical pearls discussed in the show notes for #46. These 15 clinical pearls are worth reviewing over and over.

Resources:

CT Perfusion and FFRCT are Ready for Clinical Use. Feb 06, 2017 | Christopher Maroules, MD; Ricardo C. Cury, MD, FACC Expert Analysis. Latest In Cardiology.

2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force [PubMed Citation] [Full Text HTML] [Full Text PDF]. J Am Coll Cardiol. 2016 Feb 23;67(7):853-79. doi: 10.1016/j.jacc.2015.09.011. Epub 2016 Jan 22.

Concerns regarding “2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS: Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients with Chest Pain” [PubMed Citation] [Full Text HTML] [Full Text PDF]. J Am Soc Echocardiogr. 2016 May;29(5):379-80. doi: 10.1016/j.echo.2016.02.009. Epub 2016 Feb 29.

CAD-RADSTM Coronary Artery Disease e Reporting and Data System.
An expert consensus document of the Society of Cardiovascular
Computed Tomography (SCCT), the American College of Radiology
(ACR) and the North American Society for Cardiovascular Imaging
(NASCI). Endorsed by the American College of Cardiology [Full Text PDF]

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