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KCE Reports 82 Multislice CT in Coronary Heart Disease 19
In years to come, one can expect an increasing number of asymptomatic people
emerging into the cardiologic arena because of abnormal routine tests. Multislice CT of
the coronary arteries is one of the tests that are increasingly being used, which may lead
to the identification of coronary stenoses by accident, inducing downstream
examinations and interventions that may be inappropriate.
2.6 PROGNOSIS OF STABLE ANGINA AND NON-ACUTE
CHEST PAIN
The likelihood of CAD in symptomatic patients has been estimated by Diamond and
Forrester in an often referred to study. Depending on age and gender, in patients with
atypical chest pain, the prevalence of CAD was estimated to be between 0.8 and 28.1%.
In case of symptoms of typical angina, these numbers were much higher, from 25.8 to
94.3%, depending on age and gender. 7 Data from these authors are depicted in Table 2
and Table 19.
The Coronary Artery Surgery Study that correlated clinical and angiographic findings in
20 391 patients who underwent CCA during the 1970s, showed some interesting
results. In patients with atypical chest pain, high-risk CAD, defined as left main or three
vessel disease, was rare in men younger than 70 years of age and almost nonexistent in
women of any age. 8 Besides, contrary to many patients’ (and physicians’) belief, patients
with documented CAD may have an excellent prognosis. In a series of 2170 patients
with isolated stable angina and a median age of 65 years, it was found that during a mean
follow-up of 4.9 years, 147 of these died (1.4/100 patient-years). 54 Based on 16 routinely
available clinical variables, in the same study, patients with stable angina could be
classified according to their 5-year risk of a composite of death, MI or disabling stroke,
in risk categories ranging from 4% for patients in the lowest decile to 35% for patients
in the highest risk decile. 55 The risk score used combines the following clinical variables,
in order of decreasing contribution: age, left ventricular ejection fraction, smoking,
white blood cell count, diabetes, casual blood glucose concentration, creatinine
concentration, previous stroke, at least one angina attack a week, coronary
angiographic findings (if available), lipid lowering treatment, QT interval, systolic blood
pressure ≥155 mm Hg, number of drugs used for angina, previous myocardial infarction,
and sex. Estimates of annual mortality from modern clinical trials range from 0.9% to
1.7%, with a higher mortality in populations with more severe symptoms. Reported
annual incidences of non-fatal MI range from 1.1% to 1.5%. 56
2.7 PROGNOSIS OF ACUTE CORONARY SYNDROME
Patients with ST-elevation MI (STEMI) and high risk patients with a non-ST-elevation
ACS are candidates for early reperfusion and revasculariation therapy, and will mostly
be diagnosed invasively by CCA and treated with PCI. In lower risk patients, a major
objective is to further stratify them in order to decide whether hospital admission is
necessary or whether the patient can be safely sent home, and be further examined on
an ambulatory basis, if appropriate.
Patients with no recurrence of chest pain, no heart failure, no abnormalities on the first
and a subsequent ECG and no elevation of troponins (at arrival and after 6-12 hours)
may be considered at low risk for future events and should not be submitted to early
invasive evaluation. 29 These patients may be further considered for stress testing, before
discharge or as an outpatient. 11 Some authors have questioned the incremental value
over clinical assessment of doing a stress test in the ED. It has been shown that simply
meeting the clinical criteria for having a stress test identifies individuals as being lowrisk.
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