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To Be or Not To Be

Jul 17 | 1:30 PM

There are many cases wherein we have confusion regarding the preferred line of investigation, and at such points when there is some invasive procedure involved, the dilemma is even more. CT Coronary Angiography vs Transradial Invasive Angiography is also such a point during the investigation of angina when ECG, ECHO, TMT and the overall clinical picture necessitate further investigation. Let's overcome this dilemma with some agreements and disagreements.

hello everyone we are good to go live uh i'm dr uh i welcome you all uh to a very interesting session uh a debate session uh ct and geocaching versus trunks radial and geography uh to be or not which is the preferred strategy when it comes to evaluation of china we have two esteemed speakers and an interesting moderator today with us dr kamal sharma uh interventional cardiologist at sale hospital he's author research and sir uh did one interesting session with us on top five papers earlier in kobe 19. so welcome sir we have dr komal badgama who is a consultant radiologist uh at kashman foreign and dr jaisha who is the interventional cardiologist at fcg hospital uh thanks the mom uh for joining us today today is a 48 year old male uh who's covered three months uh we want to do further evaluation uh for this and uh due to power positive family history so what is the preferred way what is the preferred strategy would it be ct and geography or transgender geography so uh first uh i'll hand it over to dr komal to talk about uh will it be a ct and geography report uh maybe after that uh dr chair you can keep it up so i hand it over to you so thank you thank you everybody especially dr kamal sharma sir and thank you dr jay so this is uh one of the few uh scenario where radiologists are sure that yes ctcag is very well established technique with very high negative predictive value that is 99.99 so uh of course we are essentially ruling out almost all clinically significant plots or disease it is fast non-invasive procedures and definitely test of choice without known cad for example in this patient test of choice in low to intermediate risk category definitely test of choice for cab cabg patients and what additional information we are going to give is calcium scoring aortic lesions such as you know ulcerative flax aortic dissection pulmonary artery embolism and lung fields especially in this covered area era so and by ctcag we are able to assess osteum anomalous course and myocardial bridging better than invasive cathangio a vulnerable black characterization is very important and ctcag is the only non-invasive modality for this characterization why and when not to do ctcag yes i agree it only gives anatomical information and we are stuck in intermediate grade stenosis and in some cases of high grade stenosis that is why ctffr was invented and initial data says that ctffr is almost equivalent to invasive ffr but yes of course ctffr is in very you know initial phases okay now over heart rate control that is for ctcag we need heart rate below 70 bpm so in high heart rates with poor breath hold in arrhythmias we get some problem in ctc reading again high end scanners are you know better in scanning these patients and they have some advantage over old scanners again densely calcified plaques will give a problem more the calcium score is more i will have low reliability or you know low confidence in reporting ctcag stents with dense fruits compromise renal function allergy to die and ionizing radiation i think the last three you know disadvantages of ctcag they are common with invasive catheters now here we see a beautiful picture of ctcag we see a soft plaque in proximal led causing mild stenosis so i mean we can depict this picture very nicely again uh partially calcified plaques the left picture is of ctcg and the right picture is of invasive catheter and we see partially calcified plaques in proximal rc causing mild stenosis and pretty much same picture of both the angios this is very beautiful volume rendered image of ctcag in cabg cases where we see uh the graph in entire you know course starting from proximal end to distal end and it is very much patent so very beautiful image again something about apc or adverse flag characterization so ctc as i said is the only non-invasive method for vulnerable life characterization generally we have four features of apc and why apc mentioning apc is important because two or more than two apc features they cause 20 increase in chances of lesion specific stimuli so what are apc features low attenuation plant positive remodeling of vessel spotty calcification and napkin ring sign so left upper image shows low attenuation plot and by low attenuation plot we means less than 30 hu of value right lower image shows positive remodeling of vessel though the lumen is not very much compromised maybe while stenosis but definitely vessel shows positive remodeling and why positive remodeling is apc feature because histopathologically such plaques are very lipid-laden and very vulnerable high necrotic core again the left upper image is of spotty calcification we see small spots less than three mm plants so again it is a feature of apc and right lower image is of napkin ring sign uh the central hypo density that is high necrotic core so these four features are ct features of apc now coming to present clinical clinical scenario this patient our patient falls into low pretest probability so i guess ctco caj is a good modality again patient has atypical angina so ct is kind of you know triple rule out uh we can see aorta aortic dissection aot calculation floods we can rule out pulmonary embolism since he is no follow-up case of covalent and again finally we can rule out this coronary thing again patient is post-covered status so lung information we are going to get extra and again if we don't get anything any information everything is normal at least we are going to get calcium scoring which is important for his risk stratification and further management hence we have no doubt that ctcs so thank you uh dr komal that was a way to put forward here but i am sure you've given enough reasons so number one uh you hopped upon non-invasive number two low risk number three is something that dr jay we would be keen to listen to dr jay the prolific speaker in cardiology so you have given apc as one thing that we are actually uh something that we need to be looking into and talking about because uh a ct angel would probably require uh profiling based on certain scoring or map camera appearances which we probably don't have on invasive angiogram so let's hear from dr j and then we can have a counter and then we can debate so dr j dr komal is saying we are non-invasive less invasive we can prognosticate and there are specific signs which you cannot get on invasive radial angiogram so let's discuss on those points and then then we can open the debate so over to dr j thank you you know giving me a very clear-cut picture of going ahead with invasive coronary angiogram in this case especially with a less invasive transmedial procedure now let us go ahead with the case scenario 48 year old male 1 postcode very importantly strong family history of pre-natural coronary artery disease now if you look at the overall classification or the definition of premature cognitive disease if you look at the framingham risk score the definition is less than 55 of age if there is a presence of estrogen in male and less than 65 of age in female that is known as premature cad but here we are talking about an indian patients so in that category i think i would uh like to invite your comments from commonwealth also that in last one decade the the definition of premature cd has changed it has changed to one decade earlier that means now we are seeing or rather defining premature cad means cd of less than 45 of age in male and 55 female and another important point which i wanted to raise is that if the patient is having a family history of premature cad what will be the risk of development of coronary artery disease in a significant form in a subs in a in a sibling or offspring you know that is the risk which is there in this particular patient and that risk is ranging from 60 to 75 percent and that has already been mentioned in the scot heart trial as well here with this case background where there is no diabetes no hypertension no non-smoker patient lipids abnormal normally cg eco but patient is having atypical angina number one number two poor effort tolerance on tmd which is also a very very hard point i would say why a patient of 48 year old male having a history of covid without having hypertension diabetes or any other risk factor designing poor rf tolerance so that requires more evaluation another important point is that what is the weight of the patient what is the bmi of the patient whether the patient has got any serial cardiac enzyme because of his a typical chase pain and if at all he is having of even a remote possibility of acs then ct angel is rolled up poor effort tolerance that itself means that patient requires further evaluation now in a background of covet 19 in uh in a scenario even though the patient is fine but you cannot rule out some of the inflammatory markers now these inflammatory markers are it's a cardiac inflammatory marker as well as the routine uh post-covered inflammatory marker which requires to be evaluated and if i quote a scott hearts trial from scotland the ctn job was being done in those category of patients where the atypical chest pain was there with the history of family history of cad and what would be the inference now the inference is that even after doing the ctn job 25 of the patient they had a obstructive ca and 38 percent of the patient they have a non-obstructive cd that means non-obstructive cd means the percentage of area stenosis will be in the range of 40 to 60 percent while obstructing seed is 65 to or more than 70 percent of the area diameter stenosis coming back to what dr komal has said that ctn joe i agree that it has got a very good negative predictive value 99 of the patient they are having a very good negative predictive value provided i am very sure that the patient is going to have a normal ngo so the risk category will be low here here anyway with premature siri we are coming into the category of intermediate or moderate rates with kovid i would still consider this patient as a moderate to high risk because the tmt the the stress test is having a poor uh effort tolerance another important point even if we do a ct engine we are not going to treat the patient on table so that on table treatment can be possible only with the help of less invasive trans radial angiography which can give you which is still a gold standard which has got a 100 specificity thermal we would be agree that we are doing it in hardly five minutes patient does not require any nvm you can allow them to take even a lower liquid there is no boundary of heart rate management keeping heart rate of less than 70 or any any chances of having a high diet overload another important point is that with the advancement in the cath lab there will not be any chance of having a poor image quality which is there with ct engines some of the scanner like if the weight of the patient is high if there is a presence of calcium then the ct angle will give you a lot of artifacts if there is arrhythmias or if there is even a uniform or multifocal vpcs area of you know the the artifacts will be very very high and as you are already mentioning that renal compromise situation or uh allergy to diet is going to be same for both the condition but we have option of using a vc pec diet completely the blood ph and the visibility ph is almost same the city enjoyed the drawback is that there is no impact on improving cardiovascular outcome that is the most important you know differentiating point in this case i would not like to tell the patient to come again and again into the hospital in the kovid era to get more exposure so once the patient is ready for less invasive trans radial angiography i'll definitely go for a live running image of coronary angiography which can give you a different angle and diagnose some of the luminal dimension or a diameter stenosis with a less amount of dye less amount of radiation less amount of procedure time and if at all intervention it is required you can do it in a single city so with family history positivity with kovid in the background the information is cannot be ruled out no really re-correcting is that because of angiography he can diagnose so many of the patients having a sluggish flu in this type of category of patient where you are falling into the category of atypical angina even a delayed diet clearance is an indication of endothelial dysfunction which is which cannot be ruled out as a coronary disease it is a coronary arteries because these patients can develop future cad if you do not treat them with the help of a good nitric oxide donor statin or antibiotic drugs so with that i think i would like to give my case as a very very strong favoring point towards less invasive trans radial angiography which can be done in five minutes even though and even if at all patient is requiring an intervention you can do it straight away provided the patient is adding acs i am sure that you are not going to do the ctn so all these factors are basically favoring uh you know trans radial angiography more in this particular case as compared to ctn procedure is also increasing so i think it's more of uh using a cat that term is invasive or using an injector in invasive so invasive definition currently has to go uh in that line number two is the need of revascularization required is that invasive or just screening it out and preventing a hospitalization that is invasive and more importantly what is invasive on pocket an angiography which is reimbursable after he is admitted or if he gets a disease and he gets admitted for an angioplasty then his ctn will be reimbursed so we have to probably justify ct to you know be reimbursed otherwise if uh it's getting invasive so that again is our invasiveness of the procedure on the pocket of the will of the patient uh so that is one but what dr jas said if you need to do procedure ct has their limitation if you don't want to do a procedure it's a screening procedure and you just want to look at overall prognostication then ctn is better if it's better in terms of calcium score it's the best predictor 10 every 10 year event rate suppose this patient was to have um a ct calcium score of say 60 70 and is otherwise no luminal occlusion normal coronary then even then a 10-year likelihood of event is high as compared to somebody whose calcium score is say zero so that way you will be able to pick up as to who is going to require an uh more aggressive management risk factor management etc yeah prognostication of ct in terms of calcium score that you cannot calculate on in so-called radial angiogram which is not so radial was the idea because it's supposed to be less invasive that the patient can actually go over three four hours a ct engine of course it's five seconds job but then we also can do a five-minute angiogram so there's the difference being the intra catholic is lying on table on both the procedure for the same time the five second difference is the time for which is injected versus five minutes where we inject otherwise on table for heart rate control or slow injection for injection force contrast for looking at the calcium probably amount of the time goes equal so i think the time die invasiveness are relative terms but i think the whole idea of to be and not to be for this case what should we undergo i think we need to bring out by contrast learning which cases to go for ctn2 and which cases to go for invasive so if you look at this guys his profile his age is 48 48 is a good age where you can do a non-invasive so-called ct angiogram rather than subject to invasive angiogram invasive angiogram would require you to have a documented ischemia this is very important remember if you have a treatment positive echo having classical angina or patient having multiple risk factors like diabetes or hypertension this debate would not have been in place that patient would have gone directly in post prove it a family history would make them a more prone to atherosclerosis but which we have counted with normal lipids so he doesn't have familiar dyslipidemia and hence probably he may not be having a very bad atherosclerotic vessels in which case ct can be a good choice if i would have mentioned abnormal lipids then it is a case of familial hypercholesterolemia then going for it invasive might have been a strategy no diabetes hypertension what i am saying is if you have ct which is uh ct if you have 48 becomes 28 you would prefer to do a ct 68 maybe invasive postponed maybe invasive family history strong may be invasive no diabetes hypertension maybe ct smoker maybe ct focus so more the number of risk factor more likely i will do invasive lesser the risk factor low risk factor maybe to a ct ct will give an advantage of looking at the lung fields which common will see for free that this patient does not have any lung disease which uh cardiologists will not know at all and normally cg also if you don't have a documented ischemia invasive angiogram is not an indication so market available and free angiography available is not an indication of doing angiography the indication of doing a free angiography is not an indication of doing angiography endography is recommended if you can document ischemia angina infection muscle at risk risk factors symptoms if you don't have them i think ct and you would be a good choice so a typical angina who effort tolerance as dr j half the point is a good point he's not able to do so we need to know why he couldn't is it osteoarthritis is it uh easily obese is he not able to do because he didn't like the machine the way here is it accustomed to it or actually that he could not finish because he's postponed so that is all the reason that would actually tilt one or the other way i think by considering both uh aspects i have touched upon and halved upon the various aspects of both of them uh one final word from each of you over to you dr kovalev and dr jay what uh common videos say that please as a radiologist give important points regarding ct coronary angiography why are you preferring city coronary angiography each of those patients and especially in postcode era what exactly is the selection criteria for doing the ct coronary angiography in your center i would prefer in young patients again young young as uh sunset is very subjective young some believe that at 50 they are young but again it is clinicians and patient choice second low to intermediate risk so that is the main criteria uh if i think that most probably this ct and geography is going to be negative or mild disease then i would go for ct and geography uh third as a radiologist i would prefer you know settled heart rate a few of the arrhythmias here and there can work but not very uh arrhythmic or not very high rate fourth i would not like to go for ct and geography in very high you know obesity because our images are no compromise in those patients uh fifth uh yes it is you know it is all personal and clinicians choice so these are the three four points what indication you want to allow google to do and what indication you will definitely do so i think invasive you have already enumerated all the causes age of the patient family history dislike anemia abnormal ecg or in all this category of patients definitely in this invasive transgenic angiography is having upper edge oversight coronary angiography in in some of the cases where i would still like to go for ct coronary angiography would be young male individual without having any major risk factors in those category of patients well clinically we are very sure that the patient is having atypical angina uh sometimes just to rule out from their you know they are a little bit uh you know mentally disturbed just because of the chest pain and due to anxiety neurosis they are getting consulted by so many other concerns and just to remove that inertia and just to remove that anxiety level from that patient where we are very sure that the patient is having a normal coronary or would be having a normal ct angiography i would definitely go for a cta coronary angiography in those category of low risk cad patient i i thank both of the speakers for a wonderful deliberation uh driven i think in low risk profile it's good to do a ct angel it's a screening procedure but if it's a high-risk case like diabetic hypertensive family history whose documented ischemia angina going invasive angiogram with a simultaneous reverse strategy is always better so i hope this session was illuminating and enlightening both of you with good counters and points from what dr komalem dr j i thank both of them from the core of their heart thank you for having us um we'll look forward to host you again for another one to be or not to be in future thank you bye you

BEING ATTENDED BY

Dr. Prasanth S & 845 others

SPEAKERS

dr. Komal Vadgama

Dr. Komal Vadgama

Coronary Imaging Radiologist | Usmanpura Imaging Centre, Ahmedabad

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dr. Kamal Sharma

Dr. Kamal Sharma

Chief of Interventional Cardiology, SAL Hospital | Author | Researcher | Innovator

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dr. Jay Shah

Dr. Jay Shah

Interventional Cardiologist | Consultant - HCG hospital, Ahmedabad

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dr. Komal Vadgama

Dr. Komal Vadgama

Coronary Imaging Radiologist | Usmanpura Imag...

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dr. Kamal Sharma

Dr. Kamal Sharma

Chief of Interventional Cardiology, SAL Hospi...

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dr. Jay Shah

Dr. Jay Shah

Interventional Cardiologist | Consultant - HC...

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