Last year there was a five-page article in the New York Times talking about CT angiograms of the heart arteries, commonly referred to as coronary arteries. The article talked about the fact that this newer technology was being over used for financial gain while there was little evidence showing it may not be any better than the older technology and also exposes the patients to the equivalent of several hundred chest x-rays and the resulting increased cancer risk. Personally, I was delighted to see this article written and expose the truth about this overused modality. Oprah and Time magazine had raved about this type of angiogram prior to this article being written but obviously they had not done their homework and explored the true factual data. The role of CT angiogram of the coronary arteries in clinical practice is not defined yet and is not an accepted screening tool for detecting blockages in the heart arteries in patients with no symptoms. Conventional coronary angiography is still the gold standard and is required by every cardiac surgeon in order to accurately assess the coronary arteries prior to heart bypass surgery. The American Heart Association does not endorse it as a screening tool or as a precursor to standard coronary angiograms either. In November 2008, an article in the New England Journal of Medicine stated, “Cardiac CT angiography misclassifies diagnosis of coronary stenosis in too many patients to replace conventional invasive imaging”. This group from Johns Hopkins University found that it misclassifies approximately 13% of the areas of narrowing and also noted that, without evidence of outcome benefit, "a high resolution cardiac CT angiographic image of the heart is just another PRETTY PICTURE." I couldn’t agree more.
I would like to share a little story about a patient a recently saw at my office in Los Angeles and his experience with the CT angiogram of the heart arteries. This Hollywood producer had gone to his cardiologist for routine stress testing and his doctor suggested that he have a CT angiogram of his heart instead. Since this is not a covered procedure by most insurance companies, he spent several hundred dollars out of his own pocket to get the test done. The test came back and he was told that he had a 90% blockage of his LAD (Left Anterior Descending Artery) of his heart, a so-called “widow-maker” lesion. His cardiologist told him that he should not exercise until he got back from his trip to Eastern Europe in three weeks at which time some further testing would be done. The patient came to see me during this time period and was frantic. I recommended to him that he should get some type of stress testing which should have been done first before any thing else was done. His thallium stress test came back normal and did not show any area of his heart supplied by this artery as having limited blood flow. It was at this time that his cardiologist came back from his trip and the patient called him and asked what he should do now. His cardiologist said that he would perform a standard coronary angiogram, which was normal. The reason I am telling this story is to show what could have potentially happen and what did happen to this nice man. First of all, he had three tests when he could have had just one. The conventional angiogram has many risks that include kidney failure and damage to the artery in the leg or wrist depending on which one is chosen to use for the procedure. Also this may have led to him having an unnecessary angioplasty and stent placement. He could have been exposed to the equivalent of nearly 500 chest x-rays because there is a tremendous difference in the amount of radiation used at different places. For more information on this topic and articles on cholesterol management, please go to http://www.lipidcenter.com
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