Clinical Question 2 Is an Urgent CT Coronary Angiogram a Good Strategy in a Patient With Undiagnosed Chest Pain?
Introduction: This situation is like the last case that I posted. Three months ago, a friend called me and said that he had had fifteen minutes of chest pain that was severe enough to worry him and it came out of the blue. He was sitting. He was at rest and he felt weak and broke out in a sweat. I think that he was a couple of days out from the pain and he had had no more trouble when he contacted me. We had to be concerned that he had unstable angina. We made sure that he was on best practice medical treatment to stabilize his coronary artery disease and he started taking an aspirin to prevent clotting. I recommended that he seek medical attention and cardiology consultation as soon as possible. I also recommended that he ask for a coronary CT angiogram. Three months have gone by, and my friend has not had a coronary CT angiogram. He has had a stress test which was normal, but as noted in my last post, you can still drop dead after a normal stress test. In England, the update to the UK NICE guidelines recommends that cardiac Coronary CT angiogram is the first-line investigation for patients presenting with new-onset chest pain due to suspected CAD. My friend is having a coronary CT now after three months of asking for the better test. Let’s see what our AI-powered medical assistant says about my friend.
Question to Ask Dr. Bill: Is an urgent coronary CT angiogram a good strategy to investigate new onset chest pain?
Answer from Ask Dr. Bill: Yes, an urgent coronary CT angiogram (CTA) can be a valuable strategy for investigating new-onset chest pain, especially in certain clinical scenarios. Here's why:
Benefits of Urgent Coronary CTA
Non-Invasive: CTA is less invasive than traditional catheter angiography.
Accurate Diagnosis: CTA can accurately detect or exclude significant coronary artery disease (CAD).
Rapid Results: CTA provides quick results, allowing for timely decision-making.
Risk Stratification: CTA can help risk stratify patients with chest pain, guiding decisions about further management.
Cost-Effective: CTA is cost-effective compared to other diagnostic strategies, such as cardiac catheterization.
Clinical Scenarios Where CTA is Appropriate
Low-to-Intermediate Risk Patients: CTA is most useful in patients with a low-to-intermediate probability of CAD.
Unclear ECG and Cardiac Enzymes: When the electrocardiogram (ECG) and cardiac enzyme tests are normal or non-diagnostic, CTA can help determine if chest pain is due to CAD.
Emergency Department Evaluation: CTA can be used in the emergency department to rapidly assess patients with chest pain, reducing the need for prolonged observation or hospitalization.
Comparison to Other Strategies
Stress Testing: CTA can be an alternative to traditional stress testing, especially in patients who are unable to exercise or have contraindications to stress testing.
Cardiac Catheterization: While cardiac catheterization is the gold standard for diagnosing CAD, CTA can help avoid unnecessary invasive procedures in many patients.
Limitations
Radiation Exposure: CTA involves radiation exposure, which should be considered, especially in younger patients.
Contrast Dye: The contrast dye used in CTA can cause allergic reactions or kidney damage in some individuals.
Image Quality: Image quality can be affected by factors such as heart rate, arrhythmias, and patient size.
Supporting Evidence
Research has shown that using CTA in the evaluation of chest pain can lead to:
Reduced Length of Stay: Patients undergoing CTA in the emergency department tend to have shorter hospital stays.
Lower Costs: The use of CTA can result in lower overall healthcare costs.
Improved Outcomes: CTA can help identify high-risk patients who need prompt treatment, potentially improving outcomes.
Keep in mind, it's always important to consult with your primary care physician before making any healthcare decisions.——————————————————————————————————-
Comment: My friend never got a coronary CT angiogram, but he is getting a CT calcium score. Let’s ask our AI medical assistant about the differences.——————————————————————————————————-Question to Ask Dr. Bill: Please explain the difference between a CT coronary angiogram and a CT calcium score.
Answer from Ask Dr. Bill: I'm happy to clarify the differences between a CT coronary angiogram and a CT calcium score, especially in the context of preventive cardiology.
CT Calcium Score
Purpose: The primary goal of a CT calcium score is to detect and quantify the amount of calcified plaque in your coronary arteries.
How it Works: It's a quick, non-invasive scan that uses a low dose of radiation to take images of your heart. The scan measures the density of calcium deposits in the arteries.
What it Shows: The result is a score that indicates the amount of plaque. A score of zero means no detectable plaque, while higher scores indicate more plaque and a greater risk of heart disease.
A score of 1-399 indicates some plaque
A score of 100-300 indicates moderate plaque deposits and a relatively high risk of heart disease over the next 3-5 years.
A score greater than 300 indicates more extensive disease and a higher risk of heart attack.
Clinical Use: Useful for risk stratification. It helps determine whether you need to be on optimal medical therapy (OMT) for coronary artery disease. As a general guide, if your score is over 100, you should consider OMT.
Limitations: It only shows calcified plaque and doesn't provide detailed information about soft plaques or blockages in the arteries.
CT Coronary Angiogram (CTA)
Purpose: To visualize the coronary arteries in detail, identifying both calcified and non-calcified (soft) plaques, as well as any narrowing or blockages in the arteries.
How it Works: This involves injecting a contrast dye into your bloodstream, and then taking CT images of your heart. The dye helps to highlight the arteries and any abnormalities.
What it Shows: Detailed images of the coronary arteries, including the presence, location, and extent of plaques. It can identify both hard (calcified) and soft (non-calcified) plaques, as well as the degree of stenosis (narrowing) in the arteries.
Clinical Use: Helps in diagnosing coronary artery disease, assessing the severity of the disease, and guiding treatment decisions. It is particularly useful for patients with chest pain or other symptoms suggestive of heart disease.
Limitations: Requires the use of contrast dye, which carries a risk of allergic reaction or kidney damage (though rare). It also involves a higher dose of radiation compared to a CT calcium score.
Analogy
Think of the CT calcium score as a basic assessment of whether there is rust (plaque) in your pipes (arteries), while a CT angiogram is like sending a camera through the pipes to see exactly where the rust is, how much there is, and whether it's blocking the flow.
Summary Table
CT Calcium Score CT Coronary Angiogram (CTA) Purpose Detect and quantify calcified plaque Visualize arteries, detect both hard and soft plaque Invasive? Non-invasive Minimally invasive (requires contrast dye) Radiation Dose Low Higher Contrast Dye? No Yes Plaque Type Calcified plaque only Both calcified and non-calcified plaque Detail Level Basic assessment Detailed visualization Clinical Use Risk stratification, guiding OMT decisions Diagnosis, assessing severity, guiding treatment
Keep in mind, it's always important to consult with your primary care physician before making any healthcare decisions.—————————————————————————————————————-Comment: My friend is very bright and has a post graduate degree. He is well insured, and he is very interested in his health. Even so, it has been very difficult for him to get the information and treatment that he needs. No matter how much money you have and how well educated you are it is very hard to get the information that helps you understand your medical problems and what can be done about them.
I just got another call from my friend, saying that he has finally had a coronary calcium score rather than a coronary CT angiogram that we asked for when he had chest pain. Here is his score copied directly from his report. Impression: 1. Quantitative coronary artery calcium Agatston score is 2419. The calcium score places the patient at the 93rd percentile for his age group. As it turns out, that gives us the information that we need to know to treat him. He will not need another test. He did not know that he had heart artery disease. Now we know that he has a heart artery plaque burden worse than 93% of men his age. He should be on best practice medical treatment, he should have nitroglycerin on hand, and he must go to the emergency room immediately if the pain ever recurs. If my friend got this report on his own, here is what our medical assistant would tell him.—————————————————————————————————————Question to Ask Dr. Bill: What does Agatston 2419 with a volume of 1910 mean on a calcium score
Answer from Ask Dr. Bill: Alright, let's break down what an Agatston score of 2419 with a volume of 1910 signifies in a calcium score. This is a high score, indicating a significant amount of plaque in your coronary arteries.
Here's a detailed interpretation:
Agatston Score of 2419: This score falls into the "high risk" category. As a reference:
A score of 100-300 indicates moderate plaque deposits and a relatively high risk of heart disease over the next 3-5 years.
A score greater than 300 indicates extensive disease and a higher risk of heart attack.
Given that your score is 2419, it suggests a considerable amount of calcified plaque.
Volume of 1910: The volume score provides additional information about the density and extent of the plaque. A higher volume generally correlates with a greater plaque burden.
What does this mean for you?
Significant Plaque Burden: The high Agatston score and volume indicate that you have a substantial amount of plaque in your coronary arteries. This plaque is made up of cholesterol deposits that have hardened over time.
Increased Risk: A calcium score of this magnitude significantly elevates your risk of future cardiac events, such as heart attack or stroke. A 2024 study indicated that patients with a CAC score of 400 or higher had a 6.8% risk of heart attack.
Optimal Medical Therapy (OMT): With a score over 100, you should be on optimal medical therapy for coronary artery disease, as this is critical for stabilizing the plaque and preventing rupture.
Do you have any further questions?
Remember, it's always important to consult with your primary care physician before making any healthcare decisions.
Final Comment: This friend’s very recent case shows how our current healthcare system lets people down. Now we know that his chest pain was unstable angina. His stress test was normal, but our last post showed you that is not reassuring in the setting of unstable angina. We have been unsure of that diagnosis for three months. We used his history to recommend best practice medical care including aspirin. That has kept him safe and lowered his risk of death ten-fold over the next five years. Our AI medical assistant has provided him with solid personalized information that he can understand. You can see how it answers his additional questions, and he can always come back and review the information.