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The SCVC Blog

Cardiovascular care news and articles from our expert team

Severe coronary disease diagnosed by CTCA

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In my medical practice, ‘diagnostic-only’ angiography has largely been superseded by non-invasive investigations, such as a CT Coronary Angiography (CTCA).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.

History and Right Coronary Artery Analysis

LAD Analysis

Left Circumflex analysis

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.

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