Rebellion21: Approach to Angina in 2021 via Tarlan Hedayati, MD

In this 14-minute presentation from Rebellion in EM 2021, Dr. Tarlan Hedayati, MD discusses the evidence base for CT coronary angiography (CTCA) and heart catheterization in patients presenting to the ED with coronary artery disease and chest pain (i.e. stable angina).

Tarlan Hedayati, MD
Emergency Medicine
Cook County Health
Twitter: @HedayatiMD

Objectives

1. Examine the diagnostic modalities in the management of angina
2. Review the evidence surrounding OMT vs invasive management of severe stable angina

Approach to Angina in 2021

• CTCA is an anatomic study that tells us about the presence and extent of CAD
  • SCOT-HEART Trial 2015 (PMID: 25788230)
    • Standard Care vs Standard Care + CTCA
    • CTCA better at identifying CAD BUT increased downstream testing
    • CTCA helped improve medication optimization (changed management) BUT no difference in CAD death or MI (patient-oriented outcomes at 6 weeks
  • SCOT-HEART Trial 2018 (PMID: 30145934)
    • 5 year follow up from 2015 study
    • CTCA increased certainty in CAD diagnosis which improved medical optimization and made a small decrease in CAD death/MI BUT no difference in rates of angiography, PCI, or CABG at 5 years
  • CTCA in the ED
    • Reserved for low to moderate risk patients
    • Increases resource utilization
    • Causes longer ED stays
    • Diagnosis of CAD in the ED doesn’t seem to improve subsequent MI or cardiac mortality at 6 weeks
    • Not a functional test
    • Only Benefit of CTCA: Good to help identify and quantify coronary atherosclerotic disease which can help with outpatient medication and lifestyle optimization
  • COURAGE Trial 2007 (PMID: 17387127)
    • Optimal Medical Treatment vs Optimal Medical Treatment + PCI in Stable Angina
    • No difference in mortality, MI, or other major adverse cardiovascular events during a 2.5 to 7 year follow up period
  • ORBITA Trial 2015 (PMID: 29103656)
    • 200 patients with optimal medical treatment x6 weeks and randomized to PCI vs sham procedure in patients with symptomatic angina
    • Exercise time in PCI group improved by 28 seconds and in sham group improved by 12 seconds (Difference of 16 seconds)
  • Coronary artery disease isn’t just about large epicardial vessels. Microvascular coronary artery disease is just as important, and no amount of stenting will fix this issue
  • Bottom Line:
    • CTCA can help identify coronary anatomy, which can help optimize medical management but doesn’t change long term patient-oriented outcomes compared to optimal medical treatment alone
    • PCI doesn’t improve death, MI or symptomatology in all comers with stable angina

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

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