alborg: Ok, I'm just a neutral medical guy, not a radiologist or invasive cardiologist, so I don't have anything to gain or lose in this situation. It's important to me in future choices of where to send my patients for their studies.
Ok, I'm just a neutral medical guy, not a radiologist or invasive cardiologist, so I don't have anything to gain or lose in this situation. It's important to me in future choices of where to send my patients for their studies.
Understandably.
alborg: Today, for example, I've had to send a woman to get an ultrasound to make sure that her post-cath right femoral pain is not associated with a bleed or an aneurysm.
Today, for example, I've had to send a woman to get an ultrasound to make sure that her post-cath right femoral pain is not associated with a bleed or an aneurysm.
Would suggest next time you refer to an invasive cardiologist who follows his/her post-cath patients more closely.
alborg: She could have averted her pain had she gone for a CT coronary angiogram.
She could have averted her pain had she gone for a CT coronary angiogram.
"The road not taken..."
A CT coronary angiogram report replete with the usual amount of hedging will likely take you back down the road leading the patient to an invasive cath because the radiologist typically punts the liability risk back to you. We do more invasive caths nowadays because of CT-CA than in spite of it because we, as invasive cardiologists, will take on the liability risk by writing definitive results in our reports. We can do this because the cath remains the gold standard when performed by those who have been properly trained.
alborg: The above study seemed to me to be fairly well designed: It was a multicenter, prospective trial (Sixteen institutions) The patient number was reasonably large (232 patients) Their findings seemed well presented: "Per-patient sensitivity and specificity of CCTA were 93 percent and 82 percent, respectively, for blockages greater than 50 percent, and 91 percent and 84 percent for blockages greater than 70 percent. In addition, negative predictive value was 97 to 99 percent." They limited their suggested patient population to "chest pain patients with a low to intermediate prevalence of obstructive coronary artery blockages" due to the high negative predictive value. This presentation to the Radiological Society of North America is a pretty big position paper. Can you find anything that might have skewed the results enough to negate these findings? One thing I see right away is that they probably do have a bias towards radiologic procedures, just as you towards "the gold standard" invasive angiography by catherization.
The above study seemed to me to be fairly well designed:
This presentation to the Radiological Society of North America is a pretty big position paper.
Can you find anything that might have skewed the results enough to negate these findings? One thing I see right away is that they probably do have a bias towards radiologic procedures, just as you towards "the gold standard" invasive angiography by catherization.
"The proof is in the pudding."
The properly trained invasive cardiologist will put down definitive findings in his/her report thereby taking all the liability exposure from you.
We can do this because of 100% sensitivity and 100% specificity.
However, our euthusiasm for invasive coronary angiography as a golden tool for evaluating coronary atherosclerotic heart disease is tempered by the fact that even among the most skilled among us, the complication rate is not vanishing to 0% so that we would not push this as a screening test. If radiologists understood that the complication rate for their CT-CA is also not vanishing to 0%, they would stop pushing it for detecting CAD in asymptomatic people.
Hope this helps you understand that only a low-cost ultra-low-risk (essentially 0% risk) test like the good old tried&true treadmill EKG test should be used as an initial test for "screening" in a symptomatic population with a low pretest probability for occlusive CAD (ie atypical chest pain in someone with an EKG amenable to EKG monitoring for signs of inducible ischemia). This recommendation is the "mainstream" recommendation given by current AHA/ACC guidelines.
gchiu: This is a turf war that the cardiologists will lose ... damm, all that training for nothing!
This is a turf war that the cardiologists will lose ... damm, all that training for nothing!
Might agree with you if our CT surgeons started to take folks to the OR relying solely on the CT-CA results.
You should see how deeply their brows furrow when they hit the hedging they encounter when they read a CT-CA report and look at the reconstructed images for themselves to understand why the radiologists are hedging. Critical information about blood flow will always be missing in CT-CA ! ! !
CT surgeons hate surprises especially while they are inside someone's chest. Go figure.
I guess they can always do an intra-operative angiogram .... but that still takes cardiology out of the loop.
Graham http://www.synapsedirect.com/ Synapse - the EMR for smart users
gchiu: I guess they can always do an intra-operative angiogram .... but that still takes cardiology out of the loop.
An intra-operative angiogram is likely to take a patient's kidneys out of the loop, Graham.
The one thing that I don't like is when they come around communities and offer executive pan-CT scans looking for CAD, aortic aneurysms, and silent carotid artery stenoses.
Interventional radiologists, though, have every other specialist pissed off at them-
They are like a fungus, I guess. It was only back in 1995 when the plight of the radiologist had hit a new low that one actually came to visit me to sell me wholesale vitamins. How far they've come in 12 years! The only reason that they don't steal away my chemo+radiation therapy patients totally is that they still want my referrals.
BTW, the great large, prospective, multicenter, randomized crossover study was found after a prolonged 3 minute search using Google, which over the past year has become my new pal.
Al Borges, M.D.
● Oncologist in a Small Group Practice in Virginia
● My website URL: http://msofficeemrproject.com/
HeartMDPhD:An intra-operative angiogram is likely to take a patient's kidneys out of the loop, Graham.
I think you need to provide us with some references for this statement.
gchiu: HeartMDPhD:An intra-operative angiogram is likely to take a patient's kidneys out of the loop, Graham. I think you need to provide us with some references for this statement.
http://dx.doi.org/10.1016/j.ejcts.2006.06.008
Eur J Cardiothorac Surg. 2006 Sep;30(3):431-5. Epub 2006 Jul 20.
INTRODUCTION: Intraoperative graft angiography is considered gold standard in quality control of innovative CABG techniques. Iodixanol, an iso-osmolar, non-ionic contrast agent has been safely applied in patients with impaired renal function. We aimed to quantify postoperative nephropathy in CABG patients undergoing intraoperative angiography and to define associated risk factors. METHODS: One hundred and thirty-five patients, aged 61 years (range: 43-83), underwent intraoperative angiography following CABG (36 robotically assisted CABG via sternotomy, 41 OPCAB and MIDCAB, 51 AHTECAB, 7 BHTECAB). In all patients iodixanol (Visipaque) was used, median amount: 150 ml (range: 20-500). Nephropathy was defined as an increase in serum creatinine concentration >or= 0.5 mg/dl compared with preoperative values. RESULTS: Nephropathy occured in 19/135 (14%) patients, and was correlated with the following variables: preoperative serum creatinine (p = 0.015, r = 0.208), age (p = 0.008, r = 0.229), postoperative peak troponin T levels (p < 0.001, r = 0.545), postoperative CK-MB peak levels (p = 0.028, r = 0.189), and presence of peripheral vascular disease (p = 0.011). No correlation was found for the contrast agent amount, diabetes mellitus, hypertension, preoperative urea level, cardiopulmonary bypass time, aortic cross clamp time, postoperative CK peak levels. Multivariate analysis showed that postoperative peak troponin T levels (p < 0.001), preoperative serum creatinine (p = 0.031), and patient age (p = 0.043) were independently associated with a postoperative increase of serum creatinine. In all 19 patients with postoperative nephropathy serum creatinine levels returned to preoperative levels. CONCLUSION: Patients with older age and elevated serum creatinine levels undergoing innovative CABG and intraoperative angiography were at increased risk of postoperative nephropathy. However, no correlation was found between the amount of contrast agent (iodixanol) applied and the nephropathy rate and none of the nephropathy cases persisted.
HeartMDPhD: In all 19 patients with postoperative nephropathy serum creatinine levels returned to preoperative levels
That hardly confirms your assertion.
gchiu: HeartMDPhD: In all 19 patients with postoperative nephropathy serum creatinine levels returned to preoperative levels That hardly confirms your assertion.
The reported rate of nephropathy in hand-picked (ie non-randomized) patients in the cited study was 14%. Most would find this rate unacceptable. You are certainly welcome to share with us your experiences with intraoperative angiography in CABG patients, Graham. Not holding my breath for this, however.
Sorry Andrew, but your assertion was that an intraoperative angiogram was likely to "take out" the kidneys.
It appears that in the study you quoted, patients with an already raised creatinine, or/and were aged, were more likely to suffer reversible renal impairment. Hardly the same thing.
gchiu: Sorry Andrew, but your assertion was that an intraoperative angiogram was likely to "take out" the kidneys. It appears that in the study you quoted, patients with an already raised creatinine, or/and were aged, were more likely to suffer reversible renal impairment. Hardly the same thing.
For your hypothetical scenario...
(1) Non-academic hospital where research is not done and where there is no budget for extra-care/caution for things that insurance will deem not medically necessary.
(2) Interventional radiologist doing the intra-operative coronary angiogram rather than invasive cardiologist.
(3) Use of more nephrotoxic IV contrast in greater quantities for the angiogram because of (1) and (2).
... the 14% nephropathy rate can easily approach 100% with folks ending up finally getting that nephrology consult as their kidneys shut down (stat consult for hemodialysis).
This I write as an invasive cardiologist with experience at both a high-volume academic tertiary-referral cardiac center (Emory University) and at high-volume private-pay non-research cardiac centers.
Glad I did not hold my breath for you to bring your clinical experience to the table.
As a primary care doc:
I was taught the principle: any hollow organ in body- it is best to view from inside to see the problem. Most problems in those are due to: intima problems- malignancies, atherosclerosis. Media and adventia usually does not get into problems (exceptions: renal artery stenosis due to media - muscular hyperplasia- in young women- problems).
Eg:
Upper GI: EGD/ERCP (Thinks changed a bit with MRCP arrival)
Colon: ColonoscopeUrinary Bladder: Cystoscope; ureter: ureteroscope
Uterus: Hysteroscope.
Coronaries: Angiograms.
etc., etc.,
Exceptions: 1. A 95 yr old who wants to know what is wrong, but does not want any thing done, even if cancer is found out- may want just an imaging- CT scan. 2. DVT- dopplers are ok, etc.
Problems with imaging: Of course if something is found out: get those scopes/caths out. If there is no problem found out and patient continues to have symptoms: still need those scopes/caths. Sometimes it helps to get patient's input, re: how far they want to go.
>>> Exceptions: 1. A 95 yr old who wants to know what is wrong, but does not want any thing done, even if cancer is found out- may want just an imaging- CT scan. 2. DVT- dopplers are ok, etc. I usually would not order it, since if nothing is to be done, then ordering the scan would be a waste of money.>>> Problems with imaging: Of course if something is found out: get those scopes/caths out. If there is no problem found out and patient continues to have symptoms: still need those scopes/caths. Sometimes it helps to get patient's input, re: how far they want to go.In the NEJM article about virtual colonoscopies, only 8% would need the scope. Heck, I'm overdue for my routine colonoscopy- I'd seriously consider the virtual spiral CT colonoscopy if my insurance company begins covering it. Many aren't.Sticking caths up folk's orifices just because we can do it doesn't mean that it'll always remain the front line procedures forever. New entities come which frequently have as much sensitivity with decreased costs and morbidity. We may or may not be there with the virtual CT scans, but in the near future many things will change (and will be things that can be discussed here as more studies come out).One thing's for sure- if I were a medical student all over again, I'd choose radiology as a specialty!
alborg: >>> Exceptions: 1. A 95 yr old who wants to know what is wrong, but does not want any thing done, even if cancer is found out- may want just an imaging- CT scan. 2. DVT- dopplers are ok, etc. I usually would not order it, since if nothing is to be done, then ordering the scan would be a waste of money.
>>> Exceptions: 1. A 95 yr old who wants to know what is wrong, but does not want any thing done, even if cancer is found out- may want just an imaging- CT scan. 2. DVT- dopplers are ok, etc. I usually would not order it, since if nothing is to be done, then ordering the scan would be a waste of money.
Without a decision tree, wiser to simply stay the course.
This study was taken to heart by HMOs.
So they created Aimee.
Goal: To educate patients re: hazards of radiation exposure
Do you like Aimee or not?
As PCPs we probably will have to jump more hurdles to get these authorized.
http://www.americanimaging.net/safety/PatientExposureTool.html
http://www.americanimaging.net/safety/