CT angiography versus functional testing for a diagnosis of coronary disease.

While Chap. 7 considered CT angiography to facilitate ER discharge in patients with chest discomfort, a recent paper compared CT to functional testing in stable out patients with chest pain. Douglas et al. randomized 10,003 symptomatic patients with suspected CAD (pretest probability >50 %) to CT versus functional testing (stress test ± echocardiography or nuclear stress test) [1]. Clinical outcomes over a 2 year follow up including death from any cause, myocardial infarction or hospitalization for unstable angina were not improved with CT angiography compared to functional testing.

Practically speaking, how should the clinician manage a patient with refractory angina as discussed in Chap. 11 who is not a candidate for any type of intervention? In addition to prescribing the maximum tolerated doses of anti-anginal medications including ranolazine and long acting nitrates, we believe that enhanced external counter pulsation (EECP) should be considered in appropriate patients. In a patient with refractory angina who is otherwise a candidate for this therapy, it can reduce anginal episodes and improve quality of life.

In the management of intracoronary thrombus in the cath lab, the final “nail in the coffin” for routine manual thrombectomy during primary PCI for STEMI was recently published by Jolly et al. [2]. In that trial, 10,732 patients were randomized to upfront manual thrombectomy versus no thrombectomy during primary PCI. More than 90 % had definite thrombus present in the culprit vessel. The primary endpoint was a composite of CV death, recurrent MI, cardiogenic shock or Class IV heart failure at 180 days. The rates were 6.9 vs 7.0 % respectively between thrombectomy and no thrombectomy groups. Stroke at 30 days was surprisingly higher with thrombectomy, 0.7 % vs 0.3 % with PCI alone, p = 0.02.

There is another method for dealing with large thrombus burdens during PCI that occasionally can be very helpful. It is never a good idea to stent or even balloon when the thrombus burden is very large. In certain situations where there is antegrade flow in the culprit vessel but either the wire or thrombectomy device cannot be passed distally that intracoronary thrombolytic therapy can help melt away thrombus. This is empiric but one editor (JA) has used, in several cases, a small doses of t-PA (10–15 mg) directly injected slowly into the coronary artery over 15–30 min [3]. If the thrombus dissolves, the procedure can then continue or the patient, if stable, can be heparinized and returned on the following day. As t-PA can activate platelets, potent antiplatelet inhibition should be instituted which, of course, increases the risk of bleeding. Nevertheless, the results are often striking with resolution of thrombus. This benefit is due to the fact that with large amounts of thrombus, there is always fibrin-rich thrombus present that responds nicely to thrombolytics particularly when there is an acute presentation.