Coronary CT Angiogram

[Irshad51]

From Irshad Khan, New Delhi, India

I have taken last week CT Angiogram and its findings are worrisome. The main impressions are:

Calcium score:      18, Soft plaques seen in proximal LAD and D1 segment.

LEFT CORONARY ARTERY

LM   -  Normal

LAD   -  (Prox/Middle/Distal)-  Type -III LAD with normal course. Focal Eccentric non-calcified plaque seen with moderate luminal narrowing.

Diagonals----  
D1    -----   Single large D1 branch seen with normal course. Mid vessel reveal plaquing with moderate luminal narowing.

Obtuse Marginal Branches

OM1   --- Normal
OM 2  ---  Large OM2 artery seen with distal branching. Proximal vessel reveal focal luminal narrowing with approx  60-65 % stenosis.

Please advise me what course of treatment is advisable.

[ed34]

You have some blockages that are mild, and some which are moderate, none which are severe. I would assume that you will be treated with medication and you should be advised of risk factors so you can reduce your risk considerably.

[jrbon]

I am just a cardiac patient, butI do not see too much reason to worry.

Depending of your age, those results can be quite normal.

How your cholesterol and BP are?

Also depending on your symptoms, you might require  stents in the OM2, or just treat it with medication or live style changes for the time been. This you have to discuss with your dr.

Meanwhile, enjoy hot Indian food but avoid fat and salt. The capsicum found in chilly and cayenne peppers is vase dilators and the curcuma has good anti-inflammatory properties.

Jesus

[kenkeith]

Q: I have taken last week CT Angiogram and its findings are worrisome. The main impressions are: Calcium score:      18, Soft plaques seen in proximal LAD and D1 segment.

....You had a CT angiogram and included is a separate procedure a calcium score.  The CT angiogram views the channel (lumen) of the vessels for any hard plaque buildup that would cause a narrowing of the vessel for blood flow and if serious could cause symptoms of chest pain, etc. Soft plaque resides between the layers of the vessel

To add what others have said. The CT score is a procedure that views the anatomy of the vessel and looking for any soft plaque that would be observed between layers of the vessel.  Your score represents  "Soft plaques seen in proximal LAD and D1 segment. LAD   -  (Prox/Middle/Distal)-  Type -III LAD with normal course. Focal Eccentric non-calcified plaque seen with moderate luminal narrowing".

Diagonals----  
D1    -----   Single large D1 branch seen with normal course. Mid vessel reveal plaquing with moderate luminal narowing".

.....The soft plaque can cause vessel remodeling...meaning the soft plaque buildup can reduce the lumen diameter without rupturing the inner layer but can bulge the inner layer into the lumen enough to reduce the diameter (positive remodeling of vessel)...if serious the stenosis (reduced diameter) can cause some obstruction of blood flow causing symptoms such as chest pain (angina pectoris).

To reduce soft plaque would be a heart healthy diet that maintains a good cholesterol levels and medication if necessary to keep cholesterol low .  If and when stenosis is above 70%, that may require intervention as that may reduce blood flow enough to cause a problem.

You have a very good calcium score...my score was very high can have a stented RCA artery, totally blocked LAD and a 72% ICX with a total over 1000 score for all 4 major arteries....prognosis is a 20% probability of a heart event within a year.  That prognosis was over 2 years ago and no problems...the CT scan was of no benefit or utility because I already knew and expected a high score...The risk with a high calcium score is that the soft plaque can rupture through the inner layer causing a heart attack.  Your score is very good but there is a beginning of CAD.

Thanks for your question. Take care,

Ken

[Irshad51]

Thanks. Your comments gave me lot of relief. I have been having  high Cholesterol which was detected 16 years ago and my triglyceride has remained out of control despite medication and diet/exercise.  The liplid profile became normal only at two occassions during  the last 16 years.

My Dr suggested CT Angio after I had a couple of episodes during very brisk climbing walk and emotional stress. Now after seeing CT he ( as well as the radiologist) told me that CT angio is not very reliable and variation may be +-10-20%.I have been advised to go for catheter angiography. In India, if one goes for this procedure most hospitals/doctors whould ask for stent/s as they make more money.

I am wondering if medication may help for the time being and angiography/plasty could be postponed. I am not sure if by postponing the procedure, how much risk I would be carrying, though I know no one can easily predict.

Any view please. Thanks

In India, i
  

[Irshad51]

My comments above speak about my cholesterol history. I do not have classical angina not have had chest pain so far in the past though I did have pressure on chest a couple of times.

My lipid profile taken two weeks ago is as under:
H Cholesterol       184               range   120-240
S. Triglyceride      278                           50-200
VLDL cholesterol   69                            10-40
HDL                      34                              >50
LDL                     111                            60-150

Ratio of Cholesterol by HDL       5.4            <4.5

[ed34]

You have to sign a consent form before the procedure, you can simply make in plain to the cardiologist, and write it on the consent form, that this is for investigation only, and in no way is intervention to be used at this time. Once this is written, they wouldn't dare insert stents because you have unquestionably stated you don't want them.

[kenkeith]

.Q:I am wondering if medication may help for the time being and angiography/plasty could be postponed. I am not sure if by postponing the procedure, how much risk I would be carrying, though I know no one can easily predict..

....If medication (nitrate) controls the episodes (assume angina pectoris) there is little to no risk to be on medication. I have been on mediction going on 8 years and no problems with any angina when exercising at medium level of activity.  I agree, if there is a cath angiogram it is likely to be a stent implant included for the reasons you cited.

A CT angiogram has a high sensitivety and selectivity rating for a CT scan with a 64 slice or greater with a 90-95% respectfully for detection of lesions greater than 50% provided the heart rate is reduced very good images (about 65 HR or lower).  

The COURAGE study (google for more info) indicates the 3 procedures (medication, stent implant and CABG) treat the symptom of angina and have no other advantage in terms of risk for a heart event.  

Hope this helps.  Take care,

Ken

[Irshad51]

Thanks. I found your answer/comments very useful and realistic and I have decided to take two more opinions from cardiologist next month. I have also decided, in consultation with my family, to avoid invasive angiography for the time being as it, I think, risk would outweigh any possible benefit.

[Irshad51]

thanks.

[Irshad51]

Thanks.

[ed34]

Just be careful when you make your decisions. At the end of the day, you should listen to professionals and there are none in this forum. You say for example that the risk would outweigh any possible benefit, but arguably, how could you possibly know that for certain?
If I left any of my blockages, I can't even say with surety that I would still be here today, nobody can. Don't read too much into trials either, because many are just too selective and techniques/knowledge grows on a daily basis. You shouldn't base your opinions on outcomes/choices of selected individuals either, treatments work very well for the majority.
For example, I have 8 stents, and require only blood thinners and cholesterol lowering meds. I had two choices, pump myself full of nitrates and beta blockers for the rest of my life (if life is what you would have really called it), or get some stents. Risks in angioplasty are very low and problems during the procedures are very rare. All I ask is that you listen to the Cardiologists you see. They can obviously only advise you, but at the end of the day, the choice is yours. I wish you good luck in your journey.

[Irshad51]

That is a reasonable suggestion. I am going to see cardiologists  early next month and then see what could be the best choice for the time being. My present cardiologist who practices non-invasive procedures has put me on aspirin 75 mg and atorvastatin (lipitor?) 10 mg. He advised me that there is no emergency but take cath angio. I have already adopted a diet and exercise regime as an attempt to retard progression of further narrowing of coronary arteries.

I will be seeing a couple of reputed cardiologists very soon though I remain skeptical about immediate stent planting in OM2 or D1.
Thanks

[Irshad51]

The forum does help in learning form people in similar health situations and possible choices.

[nagrajjain]

Can doctor rely on results from ct angiography for by-pass syrgery. Or for by-pass surgery catherter angiography is must. The discussions here are very valuable for me.

[Irshad51]

When I took my CT Angio, the radiologist told me that CT scan is not absolutely correct and may have a variation of +-10 as regards coronary arteries and that cath angio is more accurate. My cardiologist also told me that there is narrowing which has to be assessed more accurately with cath angio. As I read recently, cath angio remains the gold standard.  I also read a paper that says that CT angio is fairly sensitive and accurate and that a new machine launched by Toshiba and approved by US Govt. would give more accurate impressions.

CT angio is done in people with family heart history and those having other risk factors. This helps in making an early assessment of the condition of vessels.

Opinions are divided among specialists. Courage study done in the West shoes a considerable amount of debate and controversy. This means that doctors would be biased to their own specialization. Ultimately the patient and his/her family should choose an approach to be adopted which is low risk and high benefits. I too am confused and will be consulting a couple of cadio in Delhi next week and place the outcome summary on this site.

[kenkeith]

Thanks for your response.  I have stent in my RCA and the CT angiogram can not view the lumen inside the stent as I understand.  The diagnosis regarding the stent viability was to dteremine the flow of blood into the stented area and the output...newer technology with increased slices (256) is considered very good.

Let us know the information you receive.  Take care,

Ken .  

[nagrajjain]

Thank you all for valuable information. I hahve seen doctors manupulating results for commercial gains. That pains. Patient forum must force doctors to respond to their queries and counter check the claims by doctors.This sort of openness is necessary for the benefit of humanity.. Thank you all.
.

[ed34]

Studies can be misleading, remember they only cover a short period of time and are very specific to the types of patients who are in the trials. The courage trial basically stated the absolute obvious, and rules which most European countries have been following for years. Those are, with heart patients you have to go by two things. First is how the heart is actually functioning, and second, how the patients feels. You can guarantee that if you have 10 patients with a 70% blockage in the same part of the same artery, you will have 10 different sets of symptoms and 10 different levels of intensity. Some people feel nothing at all but their heart could be having all kinds of problems. So ALL decisions have to backed up with evidence, i.e. tests. I was intrigued for example when I read the following about the Courgage study....

Dr. Trippi, “A patient with a 70% lesion, few symptoms and good cardiac functional ability might do just as well with or without a bare metal stent provided the patient adheres to an intense regimen of medications.  It should be noted that many of the medically treated patients in the study eventually ended up with stents or coronary artery bypass because of increasing symptoms. Patients who are getting bare metal stents when they have a moderately tight blockage with controlled symptoms don't have heart attacks or die any less because they get good medical treatment for all the other less severe lesions that are just as likely to thrombose causing a heart attack as the stented lesion. This study confirms that state of the art medical treatment is effective.”

So basically, do you ignore a lesion which has the consistency for a high risk rupture and stay on medication, or do you have it stented. Other trials have shown that lesions forming in the same place as stents or thrombus forming in stents is very rare, they are much more likely to appear elsewhere, and the key it seems, is the type of material in the blockage. You have to read very carefully between the lines with studies.

I ended up having 8 stents because medication proved to be very limited in my case. For some reason they all had very little effect on the symptoms of angina. So, I had no choice if I wanted a better quality of life, and a more comfortable one. However, if medication did work for me, I would follow this protocol....
a.  What is the composition of the blockage ( is it the type more likely to erupt and possibly kill me).
b.  Does the medication I am taking relieve symptoms and enable me to do all the tasks I want to achieve.
c.  What risk factors am I ignoring and increasing my chances of developing more blockages.
If the type of blockage is one more likely to erupt, then yes I would stent. I would still have a stent if meds are working because of the risk of leaving that type of blockage. If the blockage was of the type less likely to erupt, and meds were working, then I would leave it alone for as long as possible, but in most cases, the symptoms eventually worsen.

[nagrajjain]

In my case it is vulnerable plaque as told by doctor. Doctor told me I may die at any time if quadruple bypass surgery is not done. I asked doctor why I do not have pain even on exersion. Doctor told me I have colaterals. I asked doctor do you give guarantee that after bypass i will survive at least one year. Doctor did not agree. I went then for second openion and on medicine only I survived one complete year. What you will call all this.I do not have any pain now too. Even on exersion. Thank you ed4 for your valued information. That gives me courage to put my case in proper perspective.

[kenkeith]

There is a risk with angioplasty that some people ignore and believe a stent(s) is the answer to their cardivascular chronic angina and don't consider the risks of intervention.  

The most common angioplasty risks include:
Re-narrowing of your artery (restenosis). With angioplasty alone — without stent placement — restenosis happens in as many as 30 to 40 percent of cases (requires another stent). The original bare-metal stents reduce the chance of restenosis to less than 20 percent, and the use of drug-eluting stents has reduced the risk to less than 10 percent.  For awhile DES was out of favor and a return to bare metal due to some porblem.
Blood clots. Blood clots can form within stents even weeks or months after angioplasty.

These clots may cause a heart attack. It's important to take aspirin, Plavix and other medications exactly as prescribed to decrease the chance of clots forming in your stent. My last understanding was the risk up to a year.

Bleeding: Patient may have bleeding at the leg or arm site where a catheter was inserted. Usually this simply results in a bruise, but sometimes serious bleeding occurs and may require blood transfusion or surgical procedures.

Other rare risks of angioplasty include:
"Heart attack. Though rare, you may have a heart attack during the procedure.

Coronary artery damage. Your coronary artery may be torn or ruptured (dissected) during the procedure. These complications may require emergency bypass surgery.

Kidney problems. The dye used during angioplasty and stent placement can cause kidney damage, especially in people who already have kidney problems. If you're at increased risk, your doctor may give you a medication to try to protect your kidneys.

Stroke. During angioplasty, blood clots that may form on the catheters can break loose and travel to your brain. Blood thinners are given during the procedure to reduce this risk. A stroke can also occur if plaques in your heart break loose when the catheters are being threaded through the aorta.

Abnormal heart rhythms. You heart may get irritated during the procedure and beat too quickly or too slowly. These heart rhythm problems are usually short-lived, but sometimes medications or a temporary pacemaker is needed."

Risk for medication, very few if any.  If in the future unstable angina develops and medication does not provide relief, the stent option remains to mechanically prop the vessel and there are no additional risks to forgo an immediate intervention with chronic stable angina....there are exceptions...if one is having a heart attack (acute) angina, emergency procedures are necessary.  But having chronic angina is not usually an emergency condition and that is the issue to be weighed (risk v. benefit).

Going on 8 years, I had a silent heart attack and the 98% blocked RCA and stented, but the 72% blocked ICX not stented, and I have 100% blocked LAD. Medication has provided relief from angina with moderate exerecise and not needed for every day tasks, etc.

I haven't always taken the no intervention position regarding treatment.  On another heart forum we have debated even with doctors participating that intervention was not always necessary and that was 7 years ago when it was almost unheard of to question a doctor's dx intervention for angina!  My cardiologist of non-interventional persuation and continue to be persuaded for medication therapy and as more information develops it seems to support the position of no intervention for chronic angina if medication is sufficient.

Ken

[ed34]

So with a DES, the success rate is 90% or more. Those are very good odds for anyone. Of course, restenosis doesn't mean death. This produces symptoms like those originally felt and in most cases as stated, are treated with another stent, OR, laser. Heart attacks etc during a procedure are rare, and of course can be treated while on the table. The statement "There is a risk with angioplasty that some people ignore and believe a stent(s) is the answer to their cardivascular chronic angina and don't consider the risks of intervention" is not true, ALL people are aware because they are made aware of the risks before treatment, even emergency. Stenting has without a doubt saved millions of lives.
What we have to ask, to see the other side of the coin, is how many people survive if they refuse stents. If someone is having a heart attack or very bad angina, and they refuse stents, what are their chances?

[ed34]

Just to add. It is an important factor if the lesion is concentric or eccentric. Different results from Stenting are associated with the two types.

[nagrajjain]

It looks that colateral blood circulation developped is not detected by catherter angiography. If that is the case then results will always be doubtful about so called Gold Standard.

[ed34]

I think you need to go back a step though. Why would you have an angiogram if A. there were no symptoms, or b. A stress test etc didn't reveal ischemia?
There would be a good valid reason for investigating with an angiogram. With regards to collaterals, you are correct, some are invisible because they are too fine. BUT, you can generally see in an angiogram if there is collateral feed from somewhere. I can give you such an example from my own history...
In 2007 I had an angiogram which revealed my LAD was totally blocked at the top. Now, I was not dead, so obviously there was blood coming from somewhere. When dye was injected down my Circumflex, it appeared in the LAD, showing it must be cross feeding. The blood was flowing UP my LAD instead of DOWN, another indication. You don't always have to see the collaterals themselves. But, yes, until something better comes along, angiography is the gold standard.