Hi All. Great discussion! This is a topic very relevant to my daily clinical practice where we see this type of patient population so frequently. I had an intuitive feeling that a conservative approach would be comparable to early invasive approach in this population with frailty, comorbid conditions, etc. but did not have the awareness of clinical trial data to back up that intuition.
I had 2 points of discussion that I wanted to bring up.
First is in regards to the point raised by John Mandrola and Andrew Foy about provocative stress testing for conservatively-managed patients prior to hospital discharge. I have actually stopped doing nuclear imaging in this population once I have committed to the route of medical management of a patient, since my decision about follow-up angiography tends to be driven more by symptom control or lack thereof, instead of based on nuclear imaging perfusion defects. To that end, I think it is more relevant to get a physical therapy evaluation for the geriatric patients. Getting the patient out of bed and walking if possible and seeing if this reproduces any angina at levels of activity that are normal for that patient seems more useful to me. I do this approach for a few reasons. Based on the ISCHEMIA Trial (which I know is for stable CAD patients rather than NSTEMI), I have somewhat extrapolated that even if there is some degree of ischemia, as long as I can control symptoms and risk of future events effectively with medications (antiplatelets, statins, anti-anginals), then the incremental benefit of angiography may be fairly minimal. Secondly, I am losing faith in nuclear as a modality (due to our move towards CT - Andew's skepticism of CT notwithstanding!) for risk prediction due to false positives, false negatives, and under-reporting of non-flow limiting disease which then leads to under-treatment with risk-reduction medications. I was wondering if the team could elaborate whether the decision to do nuclear stress testing prior to discharge is supported by good data or this is primarily driven by convention, habit, and "expert consensus" in the guidelines.
My second point of discussion is in regards to skepticism for coronary CT angiography. I think there are a few issues that make CCTA less effective than it could be in the United States, where the oculo-stenotic reflex is prevalent. First of all, I think when it is read by radiologists (I am biased towards cardiologists a bit), they may not be as aware of clinical literature such as COURAGE, ISCHEMIA, etc. showing high degree of efficacy of medications for chronic CAD. This awareness affects the "courage" of the reader in a sense. The unaware imager may overcall lesions or hedge because they feel that doing so will err on the side leading to downstream angiography, which could potentially reduce long-term risk by early PCI (which we know as cardiologists not to be true). When I read coronary CT, I am OK calling a lesion 60% if I think that's what it is, and I don't have to hedge and call it 60-80% because I know, even if it is 80% and I am reading it incorrectly, as long as patient is on effective medical therapy, that is first line approach to care. If the patient has Class 2-3 angina despite OMT, we can always reconsider invasive approach in the future but I know I am not affecting the ability to reduce future event risk based on what percent I call the lesion. Secondly, I know Andrew and John were concerned about the utility of CCTA in patients with prior CABG/PCI/coronary calcification in contrast to patients presenting for first time evaluation. In my practice, I find CCTA is actually quite effective for CABG patients because if the LIMA is patent with reasonable distal runoff in the LAD, I am essentially done as far as workup because any further testing probably won't confer any significant mortality benefit if patient has a patent LIMA>LAD. CCTA is VERY good at visualizing grafts and if the grafts are patent, the native vessels become less important to me (also if the native vessel runoff was poor, the grafts probably wouldn't be patent anymore from a physiologic standpoint). Also for patients with stents of 2.75-3mm diameter, our cardiology readers are quite comfortable evaluating stent patency, along with disease in the remaining non-stented vessels so I think it still has great utility there. CCTA is good at excluding left main and proximal vessel disease, and I would argue that anything in the mid-to-distal vessels is less relevant or concerning since medical management should by tried for that type of disease (and probable even for proximal disease that is stable). Also for patients with high coronary calcium, our scanner gets decent pictures and as a cardiology reader, I don't find the need to hedge on those reads either. Worst case scenario, I just call a heavily calcified segment with complete calcification all the way down to the lumen as a CTO, in which case it should be managed medically anyway! Sometimes the radiologists are less comfortable doing this, again likely due to less awareness of the clinical literature for medical management of chronic CAD. I do find a lot more hedging when CABG/PCI/calcification patients get scanned a primary radiology facilities. In conclusion, I think CCTA is a very useful tool in the hands of well-versed imager and the well-versed clinicians. However, absent those two factors, CCTA may turn into a hammer that finds nails everywhere....
We agree that early mobility in hospitalized patients is crucial—especially in older adults, where deconditioning can occur rapidly and significantly impact quality of life. As you mentioned, early mobilization also provides valuable insight into a patient's functional status and symptoms, which can help guide therapy decisions down the line.
Regarding nuclear testing prior to discharge, we don’t believe it’s necessary for every patient managed medically. While some NSTEMI trials we previously discussed used stress testing before discharge, to the best of our knowledge, there is no evidence supporting its routine use in patients receiving conservative (medical) therapy. Therefore, opting not to perform it is a reasonable approach.
Your points about CCTA are well taken. It definitely has a valuable role in selected patients and can provide important diagnostic information. Like any imaging modality, however, it comes with limitations and the potential for overuse or misuse. From your comments, it’s clear you’re well-versed in the technique and know exactly when to apply it appropriately and how to use the data correctly—maximizing its benefits. That kind of informed use is exactly what leads to the best outcomes.
Hi All. Great discussion! This is a topic very relevant to my daily clinical practice where we see this type of patient population so frequently. I had an intuitive feeling that a conservative approach would be comparable to early invasive approach in this population with frailty, comorbid conditions, etc. but did not have the awareness of clinical trial data to back up that intuition.
I had 2 points of discussion that I wanted to bring up.
First is in regards to the point raised by John Mandrola and Andrew Foy about provocative stress testing for conservatively-managed patients prior to hospital discharge. I have actually stopped doing nuclear imaging in this population once I have committed to the route of medical management of a patient, since my decision about follow-up angiography tends to be driven more by symptom control or lack thereof, instead of based on nuclear imaging perfusion defects. To that end, I think it is more relevant to get a physical therapy evaluation for the geriatric patients. Getting the patient out of bed and walking if possible and seeing if this reproduces any angina at levels of activity that are normal for that patient seems more useful to me. I do this approach for a few reasons. Based on the ISCHEMIA Trial (which I know is for stable CAD patients rather than NSTEMI), I have somewhat extrapolated that even if there is some degree of ischemia, as long as I can control symptoms and risk of future events effectively with medications (antiplatelets, statins, anti-anginals), then the incremental benefit of angiography may be fairly minimal. Secondly, I am losing faith in nuclear as a modality (due to our move towards CT - Andew's skepticism of CT notwithstanding!) for risk prediction due to false positives, false negatives, and under-reporting of non-flow limiting disease which then leads to under-treatment with risk-reduction medications. I was wondering if the team could elaborate whether the decision to do nuclear stress testing prior to discharge is supported by good data or this is primarily driven by convention, habit, and "expert consensus" in the guidelines.
My second point of discussion is in regards to skepticism for coronary CT angiography. I think there are a few issues that make CCTA less effective than it could be in the United States, where the oculo-stenotic reflex is prevalent. First of all, I think when it is read by radiologists (I am biased towards cardiologists a bit), they may not be as aware of clinical literature such as COURAGE, ISCHEMIA, etc. showing high degree of efficacy of medications for chronic CAD. This awareness affects the "courage" of the reader in a sense. The unaware imager may overcall lesions or hedge because they feel that doing so will err on the side leading to downstream angiography, which could potentially reduce long-term risk by early PCI (which we know as cardiologists not to be true). When I read coronary CT, I am OK calling a lesion 60% if I think that's what it is, and I don't have to hedge and call it 60-80% because I know, even if it is 80% and I am reading it incorrectly, as long as patient is on effective medical therapy, that is first line approach to care. If the patient has Class 2-3 angina despite OMT, we can always reconsider invasive approach in the future but I know I am not affecting the ability to reduce future event risk based on what percent I call the lesion. Secondly, I know Andrew and John were concerned about the utility of CCTA in patients with prior CABG/PCI/coronary calcification in contrast to patients presenting for first time evaluation. In my practice, I find CCTA is actually quite effective for CABG patients because if the LIMA is patent with reasonable distal runoff in the LAD, I am essentially done as far as workup because any further testing probably won't confer any significant mortality benefit if patient has a patent LIMA>LAD. CCTA is VERY good at visualizing grafts and if the grafts are patent, the native vessels become less important to me (also if the native vessel runoff was poor, the grafts probably wouldn't be patent anymore from a physiologic standpoint). Also for patients with stents of 2.75-3mm diameter, our cardiology readers are quite comfortable evaluating stent patency, along with disease in the remaining non-stented vessels so I think it still has great utility there. CCTA is good at excluding left main and proximal vessel disease, and I would argue that anything in the mid-to-distal vessels is less relevant or concerning since medical management should by tried for that type of disease (and probable even for proximal disease that is stable). Also for patients with high coronary calcium, our scanner gets decent pictures and as a cardiology reader, I don't find the need to hedge on those reads either. Worst case scenario, I just call a heavily calcified segment with complete calcification all the way down to the lumen as a CTO, in which case it should be managed medically anyway! Sometimes the radiologists are less comfortable doing this, again likely due to less awareness of the clinical literature for medical management of chronic CAD. I do find a lot more hedging when CABG/PCI/calcification patients get scanned a primary radiology facilities. In conclusion, I think CCTA is a very useful tool in the hands of well-versed imager and the well-versed clinicians. However, absent those two factors, CCTA may turn into a hammer that finds nails everywhere....
Would love to hear your thoughts on the above.
Thank you for your comment, Asghar.
We agree that early mobility in hospitalized patients is crucial—especially in older adults, where deconditioning can occur rapidly and significantly impact quality of life. As you mentioned, early mobilization also provides valuable insight into a patient's functional status and symptoms, which can help guide therapy decisions down the line.
Regarding nuclear testing prior to discharge, we don’t believe it’s necessary for every patient managed medically. While some NSTEMI trials we previously discussed used stress testing before discharge, to the best of our knowledge, there is no evidence supporting its routine use in patients receiving conservative (medical) therapy. Therefore, opting not to perform it is a reasonable approach.
Your points about CCTA are well taken. It definitely has a valuable role in selected patients and can provide important diagnostic information. Like any imaging modality, however, it comes with limitations and the potential for overuse or misuse. From your comments, it’s clear you’re well-versed in the technique and know exactly when to apply it appropriately and how to use the data correctly—maximizing its benefits. That kind of informed use is exactly what leads to the best outcomes.
Good discussion thank you