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The worry would be in a patient who has l main coronary stenosis >70% and ejection fraction < 35% .It is a possibility that a 45 year old male who smokes could have has one bout of chest pain when walking up a hill lasting ten minutes relieved by rest 12 hours ago present to his general practitioner or emergency department and asks re advice .Lmain coronary stenosis occurs uncommonly but some studies put it at 3-4 % but in a 45 year old male with high risk >25 % over 5 years of a coronary event - i have not found studies yet .
Like many scenarios in emergency medicine, there are always hypothetical patients to worry about, but it isn't clear how to translate that worry into practice. Thus far, every study of patients with negative troponins has shown no benefit with invasive management. I agree that not all coronary artery disease is the same, and I would love to see those studies broken down into subgroups. Maybe in the future we will find a subgroup - like young patients with left main disease - who would benefit. As of right now, the evidence is against such an approach.The other concern would be the costs and harms of screening for that rare patient, including the direct harms of extra CTs and angios, as well has the false positives that come with this approach.The best I can say right now is that (unlike many of our diagnostic tests) we actually have RCTs looking at CCTA - and they consistently tell us that there is no benefit from using it, so if that hypothetical patient exists, he or she is rare enough not to show up in the studies, or any benefit is balanced by harms to other subgroups.
Left main coronary disease is not hypothetical.A trial has just been published on its management -"PCI V's CABG in the treatment of "Unprotected " Left Main Stenosis The Lancet Jan 02 2020 .1201 patients enrolled from 2008- 2015 in nine Northern European Lands .PCI was inferior to CABG .So there ought to be cases that occur and it would seem worthwhile to research more on .The young middle age male is not getting healthier quite yet .
I do find this very interesting and based on the facts these tests are not all they are cracked up to be. Wish I was living in Canada where I had more medicolegal protection like Justin.
Absolutely - everyone has to work within their own system.In my mind, I think one of the best legal protections is good science. You can't be a lone wolf - but bringing evidence like this to your group can result in changes, both big and small. Good protocols, agreed on by both emergency and cardiology, can really help. You probably won't jump from admitting patients to absolutely no testing (like I am currently doing), but you might at least be able to make smaller changes, like transitioning to more outpatient testing, or at least not testing low risk patients based on something like the HEART score. It's not easy, but its worth it. Best of luck!
What you do matters.