Stress Testing for CAD in 2020: Is There Any Clarity?

Summary

The video discusses the challenges in diagnosing stable chest pain, highlighting the limitations of traditional stress tests and the potential of advanced imaging techniques like coronary CT angiography (CTCA) and fractional flow reserve (FFR). It emphasizes the importance of refining patient selection to avoid unnecessary testing and procedures. The speaker explores recent studies and trials, showing how CTCA with FFR can improve diagnostic accuracy and reduce healthcare costs. With evolving guidelines, the video suggests that CTCA may soon become the standard first-line test for stable chest pain, offering a more efficient, cost-effective approach to diagnosis.

Takeaways

• 😀 Stable chest pain is common but rarely linked to obstructive coronary artery disease, highlighting the importance of refining testing protocols.
• 😀 Over-testing is a concern in diagnosing stable chest pain, with many patients undergoing unnecessary procedures despite low event rates.
• 😀 Current U.S. guidelines recommend exercise ECG as a first-line test, while the UK advocates for CT as the preferred diagnostic tool for chest pain.
• 😀 Emerging trials like PROMISE and SCOT-HEART suggest that CT with FFR (Fractional Flow Reserve) is more effective than traditional methods at diagnosing chest pain.
• 😀 FFR-CT offers superior diagnostic accuracy, reducing unnecessary invasive procedures and offering better patient outcomes compared to traditional imaging tests like SPECT.
• 😀 The PROMISE trial demonstrated that CT with FFR could reduce cardiovascular death and myocardial infarction by up to 40% with fewer catheterizations needed.
• 😀 U.S. guidelines may soon downgrade exercise ECG from a class 1 recommendation in favor of CT with FFR, as evidence for CT becomes stronger.
• 😀 Identifying low-risk patients for deferred testing and watchful waiting is critical to avoid unnecessary testing and improve patient care efficiency.
• 😀 There is a significant cost-saving potential with the use of CT with FFR, potentially saving millions annually by reducing unnecessary procedures.
• 😀 The speaker's upcoming PRECISION trial aims to address key gaps in patient selection, test selection, and the role of FFR-CT in managing stable chest pain patients.

Q & A

What is the primary focus of the speaker in the presentation?

The speaker focuses on the challenges of diagnosing stable chest pain and the need for better patient selection and test methods. They also discuss the evolving role of imaging techniques like CT and FFR in managing these patients.

What are the major concerns regarding stable chest pain patients?

One major concern is over-testing, as most stable chest pain patients do not have obstructive coronary artery disease and their outcomes are generally very good. There is also concern about the inefficiency and limited accuracy of some diagnostic tests.

How effective are conventional stress tests in diagnosing coronary artery disease?

Conventional stress tests, including imaging stress tests, have a sensitivity of about 80%, meaning one in five patients may receive an incorrect diagnosis. The majority of chest pain patients do not have obstructive coronary artery disease, and the revascularization rates are low.

What role do guidelines play in the selection of diagnostic tests for stable chest pain?

Current US guidelines recommend exercise ECG as the only class one test for stable chest pain patients who can exercise, while the UK guidelines advocate for CT scans as the first test. European guidelines are more flexible, allowing for both imaging stress tests or CT.

What was the impact of the PROMISE and SCOT-HEART trials on diagnostic strategies?

The PROMISE and SCOT-HEART trials provided evidence supporting the use of CT with FFR as an effective diagnostic tool. The results showed that CT with FFR provided superior outcomes compared to traditional stress testing methods, with reduced cardiovascular events and unnecessary procedures.

How does the use of FFR improve the diagnostic value of CT scans?

FFR (Fractional Flow Reserve) improves CT by providing functional data on coronary lesions, allowing for better decision-making regarding which lesions are clinically significant. This approach enhances diagnostic accuracy and helps to avoid unnecessary interventions.

What are the limitations of current stress testing methods like SPECT and stress echo?

Stress tests like SPECT and stress echo are less accurate, with SPECT particularly performing poorly in comparison to CT with FFR. These tests may miss clinically significant lesions, leading to false diagnoses or unnecessary interventions.

What is the rationale behind the 'precision evaluation' strategy in diagnosing stable chest pain?

The 'precision evaluation' strategy aims to identify low-risk patients who may not require testing, focusing resources on those who need it. This approach involves using tools like the Framingham risk score to assess risk and selectively using CT and FFR testing.

How has the use of CT with FFR affected diagnostic accuracy and patient outcomes?

CT with FFR has been shown to improve diagnostic accuracy and reduce unnecessary procedures. Studies like the PROMISE trial have demonstrated that using CT with FFR results in better patient outcomes, including fewer cardiovascular events and unnecessary revascularizations.

What is the impact of diabetes on the diagnosis and management of stable chest pain?

Diabetic patients with stable chest pain are more likely to have positive test results for ischemia and worse outcomes. The PROMISE trial found that diabetic patients had a significant reduction in cardiovascular events when managed with CT and FFR, highlighting the importance of using these advanced imaging techniques in high-risk populations.