cardiac testing: the bottom line...ruling in cad •angiogram –would you send for cabg if...
TRANSCRIPT
![Page 1: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/1.jpg)
Cardiac Testing: The Bottom Line
Craig Butler MD, MSc, FRCPC
September 29 2018
![Page 2: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/2.jpg)
Outline
• Testing Overview
• Bottom line for Coronary workup
– CV Risk Assessment
– Rule in vs. rule out
• Bottom line for Myopathic workup
- When is MRI needed
![Page 3: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/3.jpg)
CAD Testing Overview
1) Invasive angiography
2) CT angiography
3) (MR angiography)
1) MRI
2) Stress echo
3) Nuclear
1) MRI
2) Echo
3) CT
4) Nuclear
Exercise Stress
1) EKG
2) echo
3) nuclear
Pharmacologic
Stress
1) Dipyridamole
a) nuclear
b) MRI
2) Dobutamine
a) echo
b) MRI
c) nuclear
Ischemia
![Page 4: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/4.jpg)
Guiding Principal 1 - Rational Approach to Investigation
National post Feb 12 2016
Hamilton Spectator Feb 11 2016
![Page 5: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/5.jpg)
Chest Pain Algorithm
Chest PainCreate a
Differential
diagnosis
Rule in
Rule out
Medical or
Surgical
Management
Gather
Information
about CC
(i.e. HPI, PE)
Pre Test Probability Diagnostic Testing
![Page 6: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/6.jpg)
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
![Page 7: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/7.jpg)
Chest pain
54 year old man
– DMII
– smoker
– prior TIA/Stroke
– Sedentary
– central abdominal obesity
– Clinic visit with atypical chest pain.
68 year old man, no risk factors, tennis 3-5x/week Clinic visit room with atypical chest pain
![Page 8: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/8.jpg)
Contributing Risk Factors
Interheart Lancet 2004
CV risk Factor Risk
Dyslipidemia 3.3
Smoking 2.9
Psychosocial 2.7
Diabetes 2.4
Hypertension 1.9
WHR 1.1-1.6
Exercise (>4hr/wk) 0.9
Alcohol (>3/week) 0.9
Diet 0.7
![Page 9: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/9.jpg)
Summarizing Risk
• Framingham Risk
• FRS – CVD
• ATP III – FRS – CHD
• Reynolds Risk Score
• AHA-ACC-ASCVD
Ten year vs. Life time risk?
![Page 10: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/10.jpg)
Overestimation of Risk
• Risk Models are generally heavily weighted to age
1900 2015
Diabetes
Lipids
Sedentary
Obesity
Smoking
Age
Diabetes
Lipids
Sedentary
Obesity
Smoking
Age
?
+
![Page 11: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/11.jpg)
Risk Refinement
• CAC adds to FRS and is better than:
– Carotid IMT
– Brachial Flow
– C-reactive protein
– ABI
Yeboah JAMA
2012
FRS +
CAC
![Page 12: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/12.jpg)
CV risk: Reclassificaton
21%
30%
Elias-Smale JACC 56, 1407
![Page 13: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/13.jpg)
Make Our Diet Great Again?
Thompson Horus Study JACC CVI 4;315
Thompson Lancet 2013
• 137 mummies (34% had vascular Calcium)– Ancient Egyptian– Ancient Peruvians– Ancestral Peubloans– Aleutian Islands
![Page 14: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/14.jpg)
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
![Page 15: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/15.jpg)
Typicality of Pain
1) Worse with activity
2) Relieved with Rest of Nitro
3) Retrosternal in location
1/3 = non-anginal
2/3 = atypical
3/3 = typical angina
![Page 16: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/16.jpg)
Pre-test prob of Obstructive CAD
Cheng Circulation 2011
![Page 17: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/17.jpg)
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
![Page 18: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/18.jpg)
Chest Pain Work up
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
![Page 19: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/19.jpg)
Ruling in CAD
• Angiogram
– Would you send for CABG if necessary?
• Trial of Medical Therapy
![Page 20: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/20.jpg)
Meta-analysis of PCI vs OMT in Ischemic CAD
JAMA Int Med2014; 172 (4):312
Death MI
Unplanned Revasc Angina in follow-up
![Page 21: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/21.jpg)
What’s at stake with Stable Angina
• Uncertainty remains about which subgroup of stable angina patients receive prognostic benefit of PCI
• Principal therapeutic goal is to:
– reduce symptoms
– treat risk factors
• Peri-procedural risk is an important offset of benefit
– Age - Lung disease - GFR
– PVD - history of CHF
Peterson et al JACC 2010;
55(18)
![Page 22: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/22.jpg)
Chest pain Pre-test probability
Typicality of Pain
Pre-test Probability
Patient CV Risk Rule in Disease
Rule out Disease
![Page 23: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/23.jpg)
Guiding Principle 2 – test Utility
Positive test resultTest with 90% sensitivity and 90% specificity
Basic Principles of Diagnostic test use and interpretation. Nicoll et
al.
![Page 24: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/24.jpg)
Rule in
Rule
out
GP 2 Test Utility –Likelihood ratio
EST: LR+ = 3, LR-=0.5
MIBI: +LR=3, -LR= 0.18
CCTA: LR+ = 7, LR-=0.06
Exercise Echo: LR+ = 8, LR – 0.2
CMRI: LR+= 4, LR-= 0.12
Trop: LR+ = 16, LR-=0.07
Banerjee IJCP 2012;66(5)
De Jong, Euro Rad 2012;22(9)
McArdie JACC 2012; 60(18)
Picano CVUS 2008;6
+LR -LR
EST 3 0.5
MIBI 3 0.2
CMRI 5 0.1
DSE 6 0.2
RbPET 6 0.1
ESE 8 0.2
CCTA 7 0.07
Troponin 16 0.07
2
4
![Page 25: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/25.jpg)
Guiding Principal 3 – Our judgement is better than we think• 400K patients without
known CAD
• ~40% stenosis >50%
• Odds ratio for + NIT = 1.3
RiskRisk +
symptoms
Risk +Symptoms
+ NIT
Patel NEJM 2010
![Page 26: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/26.jpg)
Ruling Out Ischemia
FunctionalAnatomic
CT angiogram
• Pre-test probabailty
• Test Accuracy
• Specific patient variables
Exercise(Echo,EKG)
Pharmacologic
(Echo,Nuc,MRI)
![Page 27: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/27.jpg)
Functional Ischemic TestingStress Sign of Ischemia
EKG Wall motion Perfusion
Exercise EST ESE SPECT
DobutamineDSE/DSMRI Nuclear
MRI
VasodilationNuclear
MRI
![Page 28: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/28.jpg)
Exercise Stress Test
Pro• physiologic
• Non-invasive
• Relatively inexpensive
• Readily Available!
Con• Sens = Spec = ~65%
• MSK contraindications
![Page 29: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/29.jpg)
![Page 30: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/30.jpg)
SPECT Perfusion
ProAccessible
Prognosis data
Sensitive
ConTwo day test
High radiation dose
Prone to artifact
Reader experience
![Page 31: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/31.jpg)
Vasodilator Stress
+ + +++ +
![Page 32: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/32.jpg)
Rubidium PET
Pro• Better specificity than
Spect
• One day test
• Absolute blood flow
Con• Radiation
• Accessibility
• No viability
![Page 33: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/33.jpg)
RadiationTest Dose (mSv)
MIBI 18 – 24
6 - 12
Rubi PET 3-5
Barium Enema 7
Cardiac Cath 2 – 10
Chest CT ~8
Virtual Colon 8-14
Coronary CT (64) 8-10
Dual source 128 2-4
![Page 34: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/34.jpg)
CMR
Pro• No radiation
• Safe
• Accurate perfusion
• Function
• Viability
Con• Accessibility
• Cost
![Page 35: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/35.jpg)
CMR vs SPECT
MR IMPACT EHJ 2008
![Page 36: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/36.jpg)
Stress Echo
Pro
• Physiologic
–Exercise
–Change in function
Con
• Access/wait times
• Expertise
![Page 37: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/37.jpg)
Coronary CT angiogram
![Page 38: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/38.jpg)
Coronary CT angiogram
Pro• Sensitive
• Prognostic data
Con• Radiation
• Heart rate control
• Previous revasc
![Page 39: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/39.jpg)
Scot-Heart
• N=4146
• Referred to chest pain clinic
• 18-75 yrs old
• Standard care + CCTA vs Standard care alone
• Employing CCTA– Increased the certainty
of diagnosis
– Increased diagnosis of CHD
– Decreased frequency of Diagnosis of Angina due to CHD
– Decreased use of anti-anginals
– Reduced planned investigations
Scot Heart Lancet 2015
![Page 40: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/40.jpg)
Coronary CT - Evidence in Stable Angina
• Scot-Heart (n=4146)
– Standard Care + CCTA vs. Standard Care
– Improved Clarity of Diagnosis
– Reduced number of tests required
– Trend to increased revascularization
– Increased preventative medication
– Reduced anti-anginal medication
– Trend to reduced events
Scot Heart NEJM 2018
Scot Heart Lancet 2015
![Page 41: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/41.jpg)
2016 NICE guideline update
![Page 42: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/42.jpg)
Myopathy Workup
• Heart failure reduced ejection fraction (HFrEF)
– Ischemic
– Idiopathic
– Toxin
– Familial
– Other
• Heart Failure preserved ejection fraction (HFpEF)
– Hypertensive
– Hypertrophic
– Infiltrative
Echo is first line and sufficient in most
instances
![Page 43: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/43.jpg)
When to use MRI
• Ischemic
– Diagnostic Confirmation• Mimics
– Myocarditis?
– Tako-Tsubo
– Viability pre-revasc
– Perfusion
• Infiltrative
– Amyloidosis
– Fabry’s disease
– Iron Overload
– Sarcoidosis
– (Hypertrophic)
![Page 44: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/44.jpg)
Bottom Line
CCoronary Artery Disease
Myocardial Disease
Valvular Disease
No Known Disease = CT angioKnown Disease = Nuclear or stress echo
Echo at reputable instituteMRI for Viability or HFpEF
Echo at reputable institute
![Page 45: Cardiac Testing: The Bottom Line...Ruling in CAD •Angiogram –Would you send for CABG if necessary? •Trial of Medical Therapy . Meta-analysis of PCI vs OMT in Ischemic CAD JAMA](https://reader033.vdocuments.site/reader033/viewer/2022050219/5f65140bedbf93136c0a316d/html5/thumbnails/45.jpg)
Questions?