Monday, December 20, 2010


I have written about CCTA ( Coronary Computerised Tomography Angiography ), pointing that it is not without its risks and also that the current generation ( 64MSCT ), is not yet good enough.
Well, the recent issue of Archives in Internal Medicine, Dec 13, illustrates the point. My sympathies to the patient.
A 52yrs old White Female Nurse had gone to see her own cardiologist for some mild chest pains not suggestive of angina. Her resting ECG was normal, her ipids were normal, the Hs-CRP was normal. The cardiologist decided ( although she was in the low coronary risk category ), to undertake a CCTA. The CCTA done showed discrete, noncalcified, nonobstructive plaque in the mid and distal segments of the left circumflex and dominant right coronary arteries and diffuse, complex calcification in the proximal left anterior descending coronary artery (LAD). Seeing this, the cardiologist advised a coronary angiogram, which was basically normal. However, on completion of the coronary angiogram, she complained of a severe pressing sensation on her chest. The angiographer proceeded to do an aortogram which showed a dissection of the ascending aorta, with involvement of the left main stem. The coronary circulation was severely compromised. The cardiac surgeon was called, and she underwent emergency CABG ( coronary artery bypass graft surgery ). The LVEF then was 37% ( this is a healthy 52yr old nurse ). Bad luck, the bypass graft failed and she developed cardiogenic shock. The interventionist was called and she had multiple DES ( drug eluting stents ), implanted. The DES to the left circumflex graft developed subacute stent thrombosis. The cardiogenic shock could not be reversed. She underwent urgent orthothropic cardiac transplantation.
All she needed, when first seen was a good history taking, perhaps a stress ECG ( as she was low cardiac risk ), and plenty of re-assurances, with perhaps some advice on diet, and healthy cardiac lifestyle.
Yes, this is an extreme example. Yes, this is a patient with " bad karma". But no, she did not need a CCTA, which led to the whole chain of events. CCTA is not without its risk ( including bad decision making in response ). Coronary arteriography is also not without its risk. That is why we have indications to see who needs and who does not need. CABG has risks too, and so also PCI/DES. Those of us who has done enough, have a very healthy respect for all these medical technologies, and procedures. Sometimes the " younger ones " are too "aggressive".
This case illustrates all these. That is why, I say, doing less can sometimes be more rewarding, and better for the patient.

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