Innovative approach to chest pain evaluation for traveler
One of the very frequent events that take place while traveling and has not been properly addressed over the years is the complaint of acute chest pain. This can potentially ruin the entire vacation/travel plan and would add undue stress on the travelers. Most travelers either have established coronary artery disease or risk factors for heart disease such as high blood pressure, diabetes, high cholesterol, high triglycerides, smoking, vaping, and others.
A large number of travelers are elderly with chronic diseases. On the other end of the spectrum, young travelers may also experience on occasions chest discomfort which would also cause stress and anxiety to them. Thus, I am proposing an innovative non-invasive, safe, effective, low-cost technology that will allow easy, fast, accurate assessment of the cause of chest pain as some cases of chest pain would be due to non-cardiac causes and the majority of patients can get answers with reasonable degree of accuracy that will give them not only assurance, peace of mind, save them thousands of dollars but also give them very good understanding about why they are getting chest pain and what to do about it based on the information obtained from the CTA or, Computed Tomography of the Coronary Arteries.
How many times do we see these benign looking coronary artery images on cardiac catheterization has always been taught to be the gold standard for the diagnosis and treatment of coronary artery disease affecting millions of Americans in America and around the world.
The patients are usually told that they do not have any heart disease and no specific treatment to address risk factors is offered. Some of those patients come back a few months or a year later with recurrent chest pains or even acute heart attacks. Then, they go back for the second trip into the Cardiac catheterization laboratory as acute heart attack diagnosis is confirmed with either abnormal EKG (Electrocardiogram) or abnormal blood test showing elevated troponin, which is a marker of acute heat muscle injury, or both criteria. The second look may reveal a mild (not significant ) coronary artery blockage in the range of 40-50% blockage as so many unappreciated plaques in the coronary arteries would have required on the first evaluation immediate attention with the initiation of two therapies including lipid-lowering therapy mostly with Statin therapy and if the patient is ( statin-intolerant) either due to elevation of liver functions or side effects such as muscle aches especially in the large thigh muscles of the lower extremities (i.e. Myopathy). In this situation, statin therapy would be contraindicated and thus those patients would be ideal candidates for a new brand of cholesterol-lowering drug therapy that has no side effects and was recently approved by the FDA, and only requires two shots a year.
The other therapy to start is anti-platelet therapy with either Aspirin or alternative therapy like Plavix in cases of aspirin allergy, which was proven to prevent future heart attacks by 50% with lipid-lowering and antiplatelet therapies combined as shown in many clinical trials.
This would be the new complete way to think and treat early coronary artery disease especially when it comes to the evaluation of chest pain syndrome which can be due to small vessel disease, very common in women. CTA, or Coronary Tomographic Angiography can also evaluate:
- Physiological significance of the degree of coronary artery blockages by utilizing software to assess (FFR) or Functional Flow Reserve to decide on coronary intervention only on significant blockages determined non-invasively by FFR versus continued medical therapy.
- CTA can help Assess the nature and degree of coronary blockages to plan optimal treatment strategy whether being a medical therapy, coronary stenting, or bypass surgery.
- CTA can Rule out acute pulmonary embolism as a cause of chest pain
- Rule out acute aortic dissection as a cause of chest pain.
- CTA would also shed light on non-cardiac causes of chest pain like Hiatal Hernia causing reflux disease, causing chest pain
- CTA can also show other causes of chest pain like gall bladder disease, liver cirrhosis
- CTA will show various lung diseases such as emphysema, pneumonia, lung masses, interstitial lung disease, and pleural fluid/pulmonary effusion.
- CTA will show overall heart muscle function and fluid around the heart.
- CTA will show coronary anomalies, aortic aneurysms, congenital heart disease
- CTA will help guide electrophysiology procedures such as ablation therapy and detect their complications
In summary, CTA would be the ultimate one-stop shop test to have a comprehensive evaluation of chest pain syndrome as well as all other invaluable information regarding cardiac and non-cardiac causes of chest pain.
Reference:
- Cury RC, President's page: ten years of innovation in Cardiac CT.J Cardiovascular Computer Tomography. 2014 July--Aug 8:338-339.
- Raff GL, Chinnaiyan KM, Cury RC, et alSCCT Guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain syndrome to the emergency department. J Cardiovasc Comput Tomography. 2014 July-August;8:254-271.
- Douglas PS, Hoffmann U et al. PROMISE Investigators. Outcomes of anatomical versus functional testing for coronary artery disease. N Eng J Med . 2015 April 2;372:1291-1300
- SCOT-HEART Investigators .CT Coronary Angiography in patients with suspected angina due to coronary artery disease.: An open-label, parallel-group, multicenter trial, Lancet .2015 Mar 13;6736:60291-60294
- Goldstein JA, Abidov A, et al . The CT-STAT ( Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment Trial). J Am Coll Cardiol. 2011;58:1414-1422.
- Hoffmann U, Schoenfeld DA, et al. Coronary CT Angiography versus standard evaluation in acute chest pain. N Eng J Med 2012;367:299-308
