When it comes to health, more testing is not usually better.
Believe me doc, I’m on your side here. The “worried well” are far more worried than makes sense.
I take health monitoring seriously, and follow the advice of my competent professionals. But I’m not a on a goose chase to find a reason to live on macrobiotic goat yogurt and tea enemas.
Yes and yes to @LSLGuy.
For illustration of your point - just look at the OP’s case. Now it may be that further evaluation for what the OP described as “chest pain around my heart area a few weeks prior” is appropriate; but if it happens now the hospital can thank the CAC score for having the doc and the patient taking it a bit more seriously.
And yes to intro Econ. The expensive machine is a fixed cost. The marginal cost of an additional test is very small and any revenue generated above that marginal cost is profit they would not otherwise have.
Thank you for reading through and comprehending my reason for this thread. I did have actual chest pains around my heart that I have never experienced before and my doctor recommended the CT scan as a first step of the evaluation.
From the thread I can summarize that I will most likely undergo a stress test next and the results of that will determine whether or not I require medication or further examination. Anything past that is pure what if speculation. I’ll have that talk with my doctor.
But if anyone would like to explore what ifs in this thread feel free to do so, as my reason for the thread is satisfied.
I have no expertise here. I get though that placing you in a group at higher pre-test risk of obstructive coronary artery disease would lower the bar for a more comprehensive work up than if by all measures your pre test probability was very low (eg negative family history, no high risk comorbidities, normal lipids and other blood risk markers …).
It may be that your OP buried the lede? Which is the new chest pain, not the CAC in isolation, even if the CAC ends up as the factor that increases pre test probability enough to justify the work up.
To the adult docs? What would be your approach with low pre test risk of obstructive coronary artery disease? Does using the CAC in that way make sense? Would you automatically check an EKG and HS troponin right off? Not every chest pain needs the full court press, right?
OK, maybe some more background. Besides the new chest pain I am diabetic, former smoker and Hispanic. My father and his father died of heart attacks. All of which places me in a higher risk group along with CT Scan score of 738.
That said, paging @Qadgop_the_Mercotan .
Yeah. Again no expertise but I don’t get futzing around with the CAC to risk stratify whether or not to further evaluate new onset chest pain in a 63 year old diabetic with strong family history and a smoking history. Unless it clearly fit a noncardiac cause. And maybe then.
Looking forward to getting educated!
Look, I’m a Canadian emergency doc. If you go to a cardiology conference, there are a million sponsors and luxurious free evening dinners, since the heart medicines are expensive, the new ones are not generally better than the old ones, and there are all sorts of procedures and gadgets. Emergency doctors need medicines that work, and generally these have been around for many decades. Our conferences have far fewer sponsors and freebies.
I believe strongly in the value of preventive medicine. But I also believe tests need appropriate sensitivities and specificities. Apart from tests required to meet the standard of practice, I ask myself if the result is likely to change my management.
For example, getting a full body CT if you are young and healthy is more likely to result in “we’re not really sure what this benign thing is but we should do more tests” which cause associated worry and concern, rather than it is to discover something medically important. A positive blood test saying you have a 30% chance of getting Alzheimer’s when you are old might cause you great worry, but this does not differ much from your odds if you live to be in your eighties, without doing any test. It may change what you do. But this needs to be weighed against unnecessary stress and medical costs. And can you even reliably change outcomes for Alzheimer’s?
A diabetic ex-smoker with someone close in their family with a heart attack before age sixty is already high risk and going to get those medications appropriate for that, especially if they also have chest pain.
I’ve never ordered a cardiac CT. In fairness, it is not my wheelhouse. I don’t know the literature around it. It may well incentivize people to eat better, exercise and take their medicine. It seems to provide a general picture of vascular health, but if it is not much better than a carotid ultrasound, I’d choose that since it is cheap, quick, validated and has no ionizing radiation. American doctors tend to order far more tests than the usual in Canada. Fear of litigation, more profit motive, commercial hospital ownership, “testing is good” culture, advertising and industry support, different expectations.
This doesn’t make the CT a bad test - I don’t have experience with it and am not a cardiologist. But if already higher risk, what changes were there in management as a result of this test?
My question would be whether an exercise stress test or echo (on appropriate patients) would be more likely than a heart CT to change management decisions.
FWIW found this.
https://www.journalofcardiovascularct.com/article/S1934-5925(21)00469-X/fulltext
Not sure if our OP’s new chest pain can be forced into the “stable chest pain” category, since it is indeed new, or that isn’t already high pre test risk already, but for the fake of the discussion. Section 5.3.
A recent tiered testing strategy was evaluated in both the CRESCENT I and II trials (2,4). From the CRESCENT I trial, CAC was used as the index test, with follow-up CCTA used only in patients with detectable CAC or for those with a high pretest risk (2). In this trial, nearly 40% of patients did not undergo CCTA, which reduced diagnostic evaluation costs; no events were reported in this subgroup. By comparison, nearly half of those randomized to the exercise ECG had additional confirmatory diagnostic testing. Overall, 1-year costs were significantly lower in the CAC tiered testing protocol (16% cost savings; p<0.0001) (2). Moreover, 1-year MACE-free survival was higher in the CAC-guided testing arm (97%) compared with exercise ECG (90%; HR: 0.32; p=0.011).
Such a specialized journal might not give me results I can use. Isn’t there already a high pretest risk? Thanks for the abstract though.
I would ask myself if the pain is likely due to an acute coronary syndrome. If it is cardiac pain, the fact it is new would make unstable angina likely. ECG findings and serial cardiac enzymes might show this. So might certain Bruce protocol changes while doing a treadmill (exercise stress) test. American medical costs are such a dog’s breakfast that I am not actually sure what the cost savings really means. Is that just the angio? So selected patients get contrast and more CTs and radiation? What happens next?
Specialized journal but it is the major organization guidelines for the “Evaluation and Diagnosis of Chest Pain
A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. FWIW.
Yes that’s what I am asking though? My limited understanding is that he is at high pre test risk and I doubt an even a zero CAC would be enough to counterweight that. But maybe his doc was thinking that a zero would’ve been reassuring enough?
Section 4.1 might be the relevant one? If he is classed as “intermediate risk” and new chest pain.
CCTA = Coronary Computed Tomography Angiography
FFR-CT = Fractional Flow Reserve – Computed Tomography
ICA = Invasive Coronary Angiography
My experience is cardiologists like to do tests.
The part of your abstract that gives me pause:
“From the CRESCENT I trial, CAC was used as the index test, with follow-up CCTA used only in patients with detectable CAC or for those with a high pretest risk” because as we have said, pretest risk seems high given enough risk factors in the presence of chest pain, particularly if this pain had cardiac features.
A risk score could also be found using TIMI features (age>65, ASA use in last 7d, >50% stenosis or known CAD, 3 risk factors, 2 angina episodes in 24h, ST deviation>0.5, + Troponin)
JAMA 2000;284:835
…or considering likelihood ratios (substernal pressure LR +1.3, radiate to neck/jaw LR +2.0, ddiaphoresis LR +1.4, dyspnea LR +1.2, with exertion LR 1.7, prior MI LR +2.2, positional/pleuritic/reproduce with palpitation LR +0.35 - Annals EM 2005;45:581)
There is also a GRACE risk score to decide between early(<24h) and delayed angio (72h) as an “invasive” strategy or a “conservative” strategy for doing an exercise stress test for low TIMI scores, few risk factors or the lack of recurrent ischemia.
Much of this older stuff depends on the characteristics of the chest pain. With a concerning ECG or recurrence a higher risk patient would probably get angio anyway. As you know, scientific research can take 15 years to work its way into teaching and general practice (!!), so my dated emergency knowledge is not current cardiology knowledge. But I am not yet persuaded calcium CTs are all that.
You’re definitely in a higher risk category, my friend. If you were my patient with diabetes and a past smoking history and having current chest pains (and if I were still in practice), I’d have you seen in an ER just to establish that you weren’t having ongoing cardiac ischemia/infarction that needed to be addressed NOW. Once that’s established, then it can be figured out whether to take you to the cath lab right away or wait a few days/weeks for other testing like a stress echo or nuclear stress test, etc.
Take chest pains seriously with your medical history. If you’re having those symptoms at the moment and you’ve not had a thorough evaluation for them in the recent past which ruled out cardiac causes for them, calling 911 with subsequent ambulance to the ER is the right thing to do.
More about GRACE scores. Also, as usual, Qadgop is correct. Although used for mortality, I have seen cardiologists use GRACE scores to justify doing earlier angio in ACS patients. The details and investigations regarding the chest pain here obviously make a difference, but they will likely do angio anyway regardless of the calcium score.
FWIW there are also plenty of studies, like this Iranian one, comparing TIMI scores to severity of disease on angiography.
297 patients with the mean age of 62.16±36.59 years were entered (58.2% male; 193 (65%) UA and 104 (35%) NSTEMI). The Mean TIMI score among patients was 3.21±1.55. Based on the TIMI score, patients were categorized into 3 groups. 105 (35.35%) patients had a TIMI score of 0 to 2, 120 (40.40%) had a score of 3 to 4, and 72 (24.24%) had a score of 5 to 7. Patients with a TIMI score of 5 to 7 had a greater likelihood of three-vessel coronary artery disease compared to patients with a TIMI score of 3 to 4 (OR: 5.34, 95% CI: 2.64 to 10.80; p < 0.0001) or those with a TIMI score of 0 to 2. (OR: 29.45, 95% CI: 12.87 to 67.37; p < 0.0001). Two-vessel coronary artery disease was more likely to be found in patients with a TIMI score of 3 to 4 or those with a score of 5 to 7 compared to patients with a TIMI score of 0 to 2 (OR: 3.69, 95% CI: 1.60 to 8.51; p <0.0001 and OR: 2.67, 95% CI: 1.04 to 6.82; p = 0.04, respectively).
Conclusion: There is a direct and significant correlation between TIMI score and the number of coronary vessels involved in patients presenting to emergency department following UA or NSTEMI.
I had a zero calcium score, and still ended up needing a bypass that was diagnosed by an angiogram (since I was symptomatic). Some research (on my part) showed that the CT scan was very poor at detecting “young” plaque.
It’s next week. Have you had that discussion yet? 
And really please take any additional chest pain, even brief, as serious until proven otherwise.
Yes. He told me that calcium scans cannot tell difference between build up in the arteries or on the outside of the heart. But because my dad and granddad died from heart attacks I was already high risk and has referred me to a cardiologist for stress test and evaluation. Kind of what I was expecting.
He also did not recommend changing my meds, as I am already on a Satan and low dose aspirin. While he was at it he gave me a script for Zepbound from a compounding pharmacy to help lower my A1C and maybe lose some weight.
Yeah, devil’s in the details… 