geoffrey modest medical blogs

the American College of Cardiology meeting this week had several papers of potential clinical import. one was on the relative utility of using coronary CT angiography (CTA) vs stress testing (functional testing) in patients with likely symptomatic coronary artery disease (CAD) -- see  cad testing ETT vs CTA nejm 2015  in dropbox, or DOI: 10.1056/NEJMoa1415516​ -- the PROMISE trial, an NIH supported study. details: --10,003 symptomatic patients  who were felt to need non-urgent cardiac testing were randomly assigned CTA vs exercise testing (regular ETT in 10.2%, nuclear stress testing in 67.5%, or stress echo in 22.4%; 29.4% of these tests were pharmacologic), with median 25 months of follow-up --mean age 60.8, 52.7% women, 22.6% minority, 87.7% had chest pain (72.7%) or dyspnea on exertion (14.9%). mean pretest prob of CAD was 53.3%. also 21.4% had diabetes, 65.0% hypertension, 51.1% current or past tobacco use, 32.1% had fam...

the american college of cardiology and am heart assn updated their guidelines on diagnosis and management of stable ischemic heart disease (SIHD) -- see  cad stable isch hrt dz guidelines 2014  in dropbox, or doi:10.1016/j.jacc.2014.07.017. main points: Diagnosis of SIHD  (new section on invasive testing recommendations):             --coronary angiography is useful in patients with presumed SIHD but unacceptable ischemic symptoms despite optimal guideline-directed medical therapy (class 1 recommendation, level C evidence)             --coronary angio is reasonable in those with clinical characteristics and results of non-invasive testing which suggest a likelihood of severe ischemic heart disease (eg, long-standing diabetes with end-organ damage, severe periph arterial dz such as AAA, previous chest irradiation, or patients with typ...