Providing independent clinical excellence since 2005
Posted on Friday August 25, 2023 in Health Screening
Written by Dr Edward Leatham, Consultant Cardiologist.
Invasive Coronary Angiography (ICA) is considered to be the ‘gold standard’ for the diagnosis of coronary artery disease, however it requires hospital admission and carries small risks of arterial complications including, very rarely, stroke, critical limb ischaemia, heart attack and death. We therefore tend to reserve it for high risk patients, or those who have screening tests indicating high risk, obstructive coronary artery disease.
In contrast, a CT Coronary Angiography (CTCA) is an outpatient procedure, low cost and safe.
In my medical practice, ‘diagnostic-only’ angiography has largely been superseded by non-invasive investigations, such as a CT Coronary Angiography (CTCA).
A CTCA takes just minutes to perform and is very useful diagnostic tool since it answers two key questions:
1. Is there any detectable coronary artery disease?
CTCA is highly sensitive in detecting subtle changes that occur as long as 10 years before coronary events (see coronary calcification), making it an ideal test for screening or for patients with atypical symptoms.
2. Is there severe narrowing of one or more coronary artery present in a high risk position (ie a stenosis requiring a stent)?
If one or more is found on CTCA, the Cardiologist can arrange admission for invasive angiography ? proceed to fitting one or more stents during the same procedure.
At SCVC once a patient has had their non invasive CTCA, images are immediately uploaded to our cloud workstation for the Cardiologist to review.
Our workstation images are shown in example videos below – in this case they reveal critical narrowing in two of three coronary vessels.
As soon as we found these, the patient was called and seen later the same day where appropriate medication was initiated and he was later admitted to the catheter lab, where the CTCA findings where confirmed and stents fitted to treat the two critical narrowing, thereby preventing two potentially large heart attacks that might have occurred had these coronary vessels unpredictable completely blocked.
His brief history, along with the actual workstation images used to view Coronary Arteries are shown below.
In these images the intravenous contrast is shown in grey/white filling the coronary vessels that track over the surface of the heart.
Dense coronary calcification is seen as bright white (same density as the breast bone and ribs also seen).
A coronary narrowing or stenosis caused by cholesterol deposits and atheroma build up can be seen as a filling defect (follow red arrows). A stenosis is generally only ‘flow-limiting’ (and worth stenting) if more than 75% of the cross section of the artery is obstructed by the coronary atheroma, as shown in the Right Coronary artery and left circumflex arteries below, but not in the left anterior descending vessel in this case.
Red arrows indicate the stenosis or narrowed section of the coronary artery caused by atheroma or cholesterol deposits.
https://youtu.be/w9A2-VpsuUU?si=m91iN8IFUj_LIBd_
https://youtu.be/h8EO7FfqCuk?si=eDQST-hrrVftsnnW
https://www.youtube.com/watch?v=N8BeYvN3FIo&t=1s
This case illustrates the technology we use to detect and treat serious coronary artery disease.
CTCA was recognised in 2017 by NICE as the new ‘gold standard’ for assessment of chest pains, and is thus increasingly recommended for patients presenting with many different heart symptoms, because, simply put, half of all heart disease presents with sudden death or a heart attack, and thus we all need to be looking harder to find people at risk.
The idea of predicting a heart attack may have once seemed like science fiction, but it is rapidly becoming a reality. With the advent of advanced imaging techniques and artificial intelligence, we are now able to detect the early signs of coronary heart disease and intervene before a heart attack occurs. This represents a major shift in the way we approach cardiovascular care, moving from a reactive model to a proactive one.
Is is increasingly obvious that not everyone with raised coronary inflammation and elevated risk of heart attack simply has a raised LDL Cholesterol- in fact there appears to be a mixed bag of risk factors associated with high coronary artery inflammation, including raised LDL, raised LP (a), raised Homocysteine, hypertension and dysregulated glucose. Our metabolic health assessment is therefore designed to offer a comprehensive dive into known contributory causes, the latest and most controversial of which is 'glucose dysregulation', the principle topic of this article.
For patients who have been diagnosed with an acute coronary syndrome, requiring bypass surgery or stent, or have CT Angiography and or raised FAI.
Ultimately, the approach to cardiac CT screening is highly individualized, reflecting the diverse presentations and risk factors among patients. By employing a sophisticated pre-consultation process, cardiologists can tailor their assessment and management plans to best suit each patient's unique needs, enhancing the precision and effectiveness of cardiac care.
There are two main reasons left atrial thrombus forms then detaches to cause embolic stroke. The first is that during atrial fibrillation or flutter, a thrombus may develop in the left atrial appendage, which does not move as much as it does when in sinus rhythm. The likelihood of this occurring in any given year is low, correlated to the CHA2DS2-VASc score. The second reason is not related to CHA2DS2-VASc score
Lp(a) testing is advised for individuals at high risk for cardiovascular disease, including those with a prior stent or bypass operation, coronary syndrome or heart attack as well as anyone with a family history of coronary heart disease, high FAI (coronary inflammation) or high risk patterns on Cardiac CT angiograms. In our practice, Lp (a) is offered as part of our comprehensive Metabolic Health assessment (MHA1).
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