(wow) Words Of Wonders Level 909 Answers – Authors: Dr. Evan Harmon, Dr. Pamela Douglas, Dr. Greg Katz, Martin Fried and Dr. Shreya P. Trivedi
E: Guys, as you all know, after reading about stress measurement, I seem to have discovered a very unpleasant concept that many of us simply don’t know about.
(wow) Words Of Wonders Level 909 Answers
E: When we think about stress testing — like all the different types of stress testing that we’ve looked at in the previous part — that’s only half the story when it comes to diagnosing increased CHD risk.
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E: Yes, yes – the whole episode is worth it! There are actually two broad categories of CAD tests: functional tests and anatomical tests. The final part is functional testing – studies such as stress ECG, stress echocardiogram and nuclear tests. There’s a whole set of tests — anatomy tests.
S: Of course! So it might be useful to differentiate between the two types of tests…so what I take from the last 5 gems is that the stress test shows our body the results of the intervention. So when a patient is stressed, this test helps me see if there is ischemia, which shows up in things like ECG changes or wall motion. But it seems like these stressors don’t tell the whole story:
PAMELA DOUGLAS: In the stress test, you just don’t have ischemia, but maybe you know, there’s ice under the surface that you didn’t know, and you can see it with CT.
E: According to Dr. Douglas, these stress tests don’t tell us anything about the patient’s anatomy or the amount of plaque.
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E: Yes, we have to be careful how we use the term “coronary CT,” which is often linked together. Coronary CT is a term that includes several similar but separate tests, both of which involve: calcium assessment in the coronary arteries and coronary CT angiography (or CTA).
S: Okay, let’s start with the big picture – we’ve been talking about a decrease in pressure performance, and that’s only half the story, is there an anatomical effect?
M: Right, so anatomical tests give us information about the patient’s anatomy and the severity of the plaque, but they don’t tell us whether the plaque is causing ischemia.
PAMELA DOUGLAS: It’s entirely possible to have tight wounds — anatomically tight, not to cause serious side effects, and actually quite common.
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S: So far I’ve heard from this pearl about diagnosing coronary artery dissection, we have functional tests in our arsenal, which is the classic “stress check test” that tells us about ischemia, but Not our existing model. Anatomical tests, such as coronary CT, including calcium readings and coronary CT, help us better understand plaque, but don’t tell us what’s important if plaque is causing ischemia.
E: But don’t rush to conclude, Shrei. Dr. Douglas warns us that with new technologies such as Fractional Flow Reserve CT (also known as FFR-CT), we will be able to obtain anatomical and functional information.
PAMELA DOUGLAS: CT Ffr comes from, it’s not, ahem, derived from CT anatomical images that have been acquired, ahem, from, ahem, big data processing for simulating coronary blood flow. It can simulate, um, the hemodynamic implications of the disease, like the invasive fractional flow reserve, or invasive FFF, which itself became the gold standard for coronary artery disease.
S: For us non-cardiologists, relevant Dr. FFR. Douglas talked about what happened in the cath lab. Remember, in the operating room, you’re trying to see if the lumen is narrowing, but during surgery, cardiologists also have access to what’s called a “Fractional Flow Reserve”—a score that shows us how important blood flow is to the heart. Kinetic special test report muscle. Wounds – it’s all invasive. So the great thing about FFR-CT is that it’s non-invasive and uses good CT images, puts all of these images together, does some crazy math, and gives us real information about the blood going through the cells.
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M: [anxious “heart roar” interrupted by Marty]. That’s my voice. But most importantly, some FFR-CT techniques are proprietary, i.e. very expensive. For the sake of completeness, we include it here, but as a reminder, in this section, we will focus primarily on arterial calcium and coronary CTA, as these are the tests most staff deal with on a daily basis.
S: Let’s start our coronary CT journey with a calcium reading. Today I’m a doctor and I see calcium levels based on the patient’s previous visits, or sometimes added to the coronary CTA, but I don’t really know what to do with it. I really love the who, what, when, where, and why of every aspect of calcium readings.
M: Yes, let’s go back to basics. Coronary artery calcification usually means severe atherosclerosis, and that’s important…Excessive coronary artery calcification has been shown to be associated with heart disease in asymptomatic people, and is also not appropriate for people with coronary artery disease.
E: The test to crack the system was simple – just didn’t have a mental comparison of about 10-15 minutes and what the workers were wearing.
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S: Okay, but how come CT doesn’t provide coronary artery calcium (CAC) readings? According to the conclusion, what does the coronary calcium index mean?
E: If there are calcium plaques, their density is measured in Hounsfield units and divided by the lesion area. So the computer really just adds up the total scores for all the plaques to get a composite score that reflects the total amount of plaque in the patient’s coronary arteries.
Subject: Ok, fine, if the model tells us the level of calcified plaque, which score should we care more about than the other?
M: The short answer here is that we should focus on people with scores above 0. To help you assess, many studies stratify patient populations—usually 0-100, 101-400, and 400+.
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E: It’s important to know that counting isn’t the only thing we care about. A calcium level of 50 in a 35-year-old man is not the same as a calcium level of 50 in an 80-year-old woman. To get a full picture of a person’s risk for CHD, we need to monitor the patient’s age, race, and gender. So, here’s a calculator that can help us with that: the Mesa Calculator. Anyone over 75% of age, gender, and race is generally considered to need a statin prescription.
Man: Yes. The Mesa calculator is very useful for interpreting CAC results. Just to highlight the various benefits of statins with increased CAC rates, I would also like to mention an excellent 2018 paper by Mitchell in JACC. aluminum. The authors found that as CAC increased, NNT decreased with statin treatment. Therefore, if a patient has a low calcium score, say 1-100, the NNT of a statin would be 100 to prevent 1 adverse cardiovascular event (MACE) in that patient. But if the score is >100, the NNT of the statin will be reduced to 12 to prevent the patient’s first major CV event.
S: OK, thanks for your setup. What’s at the other end of the coronary calcium spectrum? How does calcium help us zero in?
E: So zero is the best score. Dr. has a very good idea. Yale’s Nasir calls it “the power of zero.” The TL;DR version is that patients with a CAC score of 0 do not need to start statin therapy, and statins were not associated with reduced side effects in this group.
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M: So the idea of zero degrees is very important, because for someone at intermediate risk, there are many factors (S: 10-year ASCVD risk of 5-20%) that make you worry about the patient – like premature heart disease in the family or Autoimmune diseases such as rheumatoid arthritis all increase risk, but not many of them reduce risk for patients. Nothing can make you less anxious. A CAC score of 0 is one of them! This allows us to reduce a person’s risk from moderate risk to low risk, and it’s very powerful. This allows us to confidently identify low-risk patients who were previously high-risk and therefore do not require statins!
S: Yes, it’s really popular. For me, it’s also very important. Well, let’s change energy to how we use those calcium credits. Well, when I put on my hospital hat, I thought about the patients that came to mind.
