Most sensitive test to pick up heart disease/cad

[miamidoc2b]

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Hey guys - I am Anes/pain and had an interesting discussion with a patient yesterday. Somehow the topic of heart disease came up and I was asked what is the best test to pick up CAD. I told the patient I don't honestly know as there are tons of tests and to touch base with PCP/cards. So here I am asking you guys for input. I suppose the best would be a cardiac cath, but short of a cath, which is "best"?

 

[Raryn]

Hey guys - I am Anes/pain and had an interesting discussion with a patient yesterday. Somehow the topic of heart disease came up and I was asked what is the best test to pick up CAD. I told the patient I don't honestly know as there are tons of tests and to touch base with PCP/cards. So here I am asking you guys for input. I suppose the best would be a cardiac cath, but short of a cath, which is "best"?

Depends on the patient.

In general, cath is your gold standard. Even that isn't perfect in certain populations (a number of women) due to a difference in plaque structure and the actual mechanism of MI.

Next best? Well, there's some great evidence about cardiac CT (which very well might be next best thing actually available outside of some research protocols), but if someone is actually asking you, they probably want to see how well you understand stress testing. The "best" type of stress test varies depending on the patient, but an exercise stress test with some kind of imaging (whether nuclear or echo) is in most studies your highest sensitivity (~85% sensitivity), then a pharmacologic test with imaging (~80%), then the classic old exercise EKG. (~70%) We had a recent thread at http://forums.studentdoctor.net/threads/ordering-a-right-type-of-stress-test.1201574/ that went into more detail on stress testing.

 

[Instatewaiter]

Hey guys - I am Anes/pain and had an interesting discussion with a patient yesterday. Somehow the topic of heart disease came up and I was asked what is the best test to pick up CAD. I told the patient I don't honestly know as there are tons of tests and to touch base with PCP/cards. So here I am asking you guys for input. I suppose the best would be a cardiac cath, but short of a cath, which is "best"?

Your question is unclear.
- Do you want to pick up clinically meaningful CAD or any CAD?
- Is this to find CAD or truly for prognostication on mortality?
- What setting are we talking about- in the setting of MI, in the setting for pre-op risk stratification, just as an outpatient?

If you are looking to diagnose any CAD with any modality- IVUS or OCT would probably be the best. However, it would be stupid for a asymptomatic patient to have a wire down a coronary much less a cath and as such, you're not going to have anyone perform a study on asymptomatic patients.

If you are looking to find some CAD without being invasive, a coronary gated CT is pretty sensitive, but this is going to break down if you use it in low risk patients.

 

[deleted547339]

It really depends on your definition. It is unclear if CAD is/should be a physiologic diagnosis or anatomical diagnosis, but with the advent of interventional imaging (be it LHC, coronary CT, etc) it has become an anatomical diagnosis.