WCM-Q Grand Rounds discusses medical evaluation of chest pain

Dr Subhi J. Al’Aref, assistant professor of medicine in the Division of Cardiology and director of Cardiac CT at the University of Arkansas for Medical Sciences, delivered a live webinar in which he reviewed the existing paradigm for chest pain evaluation. He then described the technique of non-invasive anatomic evaluation for patients presenting with chest pain, particularly in cases of suspected coronary artery disease. Dr Al’Aref is an alumnus of WCM-Q, having graduated from the college in 2008. Using real-life examples, Dr Al’Aref explained the major differences between anatomical and functional testing for chest pain. Anatomical testing generally involves a computed tomography (CT) scan, which utilises rotating X-ray machines and computers to create cross-sectional images of the internal structures of the body – in this case, the heart and blood vessels. Functional testing utilises a number of other modalities, such as an exercise electrocardiogram (ECG), to assess the heart’s response to exercise; nuclear stress testing, which uses a small amount of radioactive tracer material inserted intravenously and an imaging machine to assess blood flow in the heart both at rest and during activity; and stress echocardiogram, which uses ultrasound waves to assess the function of the heart during exercise. Dr Al’Aref also mentioned that the heart can be stressed using pharmacologic means for the purposes of evaluation in cases where a patient is unable to perform exercise for any reason.He also provided an evaluation of the existing scientific literature supporting the use of anatomic evaluation over stress testing for identifying obstructive coronary artery disease. Citing a study published in the 'New England Journal of Medicine' in 2010 that analysed data from almost 400,000 patients, Dr Al’Aref said: “Stress testing is really not accurate at identifying obstructive coronary artery disease. They found that 67% of patients who had an invasive coronary angiogram and a stress test at baseline did not have obstructive coronary disease. This is mind-boggling because the purpose of doing a stress test is to find out who does and who does not have significant disease so you can do an invasive evaluation. "So, the fact that we are sending more patients than we should be and finding out that they don’t have any significant disease is obviously sub-optimal.”In conclusion, Dr Al’Aref said the research literature indicates that computed tomography angiography (CCTA) accurately discriminates between non-obstructive and obstructive coronary artery disease and should be considered an effective ‘gatekeeper’ for determining which patients should be referred for invasive coronary evaluation. Furthermore, coronary evaluation using CCTA can benefit patients in terms of both short- and long-term health outcomes by indicating patient-appropriate and disease-specific therapies.The lecture, titled 'Chest Pain: Anatomic vs. Functional Evaluation', was accredited locally by the Ministry of Public Health’s Department of Healthcare Professions – Accreditation Section and internationally by the Accreditation Council for Continuing Medical Education.