This document discusses cardiac decision making and provides guidance on testing options for various patient cases. It outlines tools like CT coronary angiography, cardiac MRI, nuclear scans, PET scans, stress tests, and IVUS/OCT. It provides recommendations on when to use each test based on factors like pre-test probability, symptoms, risk factors, and prior procedures. The document also analyzes several patient cases and suggests the best testing approach for each case.

1. Cardiac Decision Making
Dr. Dibbendhu Khanra
DM Cardiology
Interventional Cardiologist

2. Ischemia
Viability
Goal

3. Choices!
Mans
• Radiologists
• Nuclear Medicine
• Non-interventionists
• Interventionists
Tools
• CT Coronary Angio
• Cardiac MRI (CMR)
• Nuclear scan
• FDG PET
• TMT
• Dobu stress echo (DSE)
• IVUS
• FFR/IFR

4. Chest pain
• Central chest pain
• Exertional. Decreases in rest/ sorbitrate
• Radiation
3+ typical angina
2+ atypical angina(DM aged female angina equivalent)
0-1+ nonspcf chest pain (NSCP)

5. Risk factors
• Aged
• Smoker
• DM
• HTN
• Dyslipidemia
• FH
• Prev MI or Prev stenting/ known CAD (CAG done
• Stress
• OBESITY

7. Probability
• Very low prob (<10%) : no test
• Low prob (>90%) : CT angio/ CAC---CAG
• Intermediate prob (30-60%) : stress test
• High prob (60-90%) : CAG
• Very high prob (>90%) : CAG

9. Case 1
• 28 year female
• Nonspc chest pain
• No risk factor
• ECG normal
• ?

10. TMT
• R/O AS
• Pre-test prob
• HR
• BP
• Mets
• Angina
• ST change
• Inf leads beware
• Females beware
• Recovery
• Tachy not receoved
• ST elevation

13. Case 2
• 45yr male
• Smoker
• Typical chest pain
• ECG normal
• ?

15. Case 3
• IWMI STK+ 3 hrs
• No chest pain
• Time to discharge
• ?

17. Case 4
• PTCA to LAD
• No chest pain/ fatigue+
• EF30%-45%
• 6 weeks
• Wants to start jogging?

19. Case 5
• 40 yr lady
• DM on ecsoprin av
• ECG – ST T changes
• h/o atypical angina
• Posted for lap chole
• Surgical fitness?

21. Case 7
• Plan for hernioplasty
• ECG sinus brady
• Thy normal
• Holter normal
• Fitness?

22. Case 13
• 75 yr frail lady
• Atypical chest pain
• HTN DM
• ECG : WNL

24. Case 18
• 16 yr old girl
• ECG CHB narrow QRS
• Echo CCTGA
• ?PPM

25. Case 20
• CAG done
• LAD seen
• LCX not seen
• Right sinus: could not be hooked

26. When I advise TMT?
• Intermediate prob
• Post STK
• Post PTCA
• Pre-op
• Cong CHB
• Anomalous coroanry

27. Case 16
• 40 yr IT stressful
• Smoker
• Atypical chest pain
• ECG LBBB
• ?

28. When to stop TMT?
• Chest pain and ST changes
• VT
• Patient fatigue SOB
• BP>180
• ST elevation

29. When I do not advise TMT?
• Pt is very symptomatic
• Elderly frail
• Obese lady
• Fit young
• LBBB
• Preexcitation
• LVH/ strain
• Cong CHB

30. Case 9
• Very obese lady
• Atypical chest pain
• HTN
• ECG normal
• ?

31. CT coronary angio

32. Case 14
• PTCAX2
• CABG
• Still angina
• ?

33. Case 12
• Sev AS, mod AR
• Planning for AVR
• CVTS referred for CAG before evaluation
• ?

34. Case 19
• 65 yr old
• Post CABG
• CT angio
• Dense coronary ca
• ?

35. When I advise CT coronary angio?
• Low prob
• Anomalies
• Aortic dissection
• CTO
• Post CABG
• Pre-AVR/Pre-ICR

36. Case 6
• AWMI 2 weeks back
• No angina DOE II
• EF 20%
• ?

40. Scar
P-M-
Stun
P+M+
Hiberbating
P-M+
Early interv
P=M-
FDG PET

41. Case 21
• AWMI PTCA TO LAD
• Also LCX 90%
• RCA 80%
• Angina
• ?

42. When do I advise nuclear scan?
• MVD angina - ischemia
• Post MI – viability
• LBBB, TMT can not be done
• Frail pt, TMT can not be done
• CTO – viability/ stress ischemia

43. Case 15
• 24 M
• No risk factor
• No chest pain
• SOB 2M
• EF 20%
• ?

44. CMR

45. Case 10
• 3m ago AWMI
• EF still 15%
• Ant wall akinetic
• Thickness maint
• Atypical angina
• ? PTCA

46. When do I advise CMR?
• Young DCM
• Primary ICD
• VT
• Myocarditis
• HCM w/o HTN

47. Case 11
• Typical angina
• CAG done
• LAD mid 70%
• ?

48. IVUS
OCT

50. What we have learnt?
• Resting ECG is good for ischemia
• Angio is not benign
• TMT in who can complete
• Nuclear scan alternative/ MVD
• Viability sn FDG PET
• Viability sp DSE
• CMR for CMP/ VT/EF
• Intermediate: IVUS FFR