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When Is An Angiogram Not Advisable?
Question: Is there any way to get a ct coronary angiogram if my primary or specialist won't order one?
Brief Answer:
My opinion as follows:
Detailed Answer:
Hello!
Welcome back on HCM!
Regarding your concern, I would like to explain that coronary angio CT is a valuable cardiac test for evaluating the overall coronary calcium score, which when revealed abnormally high may suggest coronary artery lesions.
Also, coronary angio CT may directly evaluate coronary arteries for possible coronary lesions (stenoses).
Indications for a coronary angio CT include an intermediate pretest probability for coronary artery disease.
An example would be a middle age individual with a suspicious chest pain and several known coronary risk factors (like hypertension, diabetes, smoking habit, dyslipidemia, or heredity for CAD, etc.) coupled with other evidence like a suspicious ECG.
Considering your young age and your gender (females are quite protected at similar age from experiencing cardiac ischemia issues), it would not be rational asking a coronary angio CT by a PCP or cardiologist.
This is because in such a young age as your are, it is quite unlikely to have a high overall coronary calcium score (unless you have any important health disorder such as severe chronic renal dysfunction, etc.) or to suffer from coronary artery disease (unless strong heredity, diabetes mellitus type I, a familial homozygous hypercholesterolemia, etc. exist).
Furthermore, coronary angio CT imposes the patient to a high burden of radiation, and for such reasons the risk of radiation should be overcome by the beneficial diagnostic information obtained.
If you don't have a suggestive symptomatology for cardiac ischemia (chest pain on exertion, or recently deteriorating chest pain); if you don't have coronary risk factors (hypertension, diabetes, dyslipidemia, smoking habit, heredity for premature coronary artery disease) or other diseases like severe chronic renal disease, familial homozygous hypercholesterolemia, etc. then coronary artery disease is not scientifically justified and would bring more harms than useful information.
But, if you insist in performing a coronary angio CT, you should evidence about the presence of coronary risk factors (as mentioned above) coupled with a suggestive clinical symptomatology for cardiac ischemia.
On my personal professional opinion, in your case a coronary angio CT would not yield any beneficial diagnostic results.
Instead, it would be more advisable to undergo an exercise cardiac stress test or an Dobutamine stress echo as the harm of radiation is not present.
That's my personal professional opinion.
Please, could you give more clues on why you are thinking to undergo through a coronary angio
CT?
Do you have any specific complaints recently?
What about potential coronary risk factors?
And your recent ECGs??
Hope to have clarified your uncertainties!
I remain at your disposal for further discussions in case you provide me with additional information regarding your suggestive clinical symptomatology and available medical tests.
Kind regards,
Dr. Iliri
My opinion as follows:
Detailed Answer:
Hello!
Welcome back on HCM!
Regarding your concern, I would like to explain that coronary angio CT is a valuable cardiac test for evaluating the overall coronary calcium score, which when revealed abnormally high may suggest coronary artery lesions.
Also, coronary angio CT may directly evaluate coronary arteries for possible coronary lesions (stenoses).
Indications for a coronary angio CT include an intermediate pretest probability for coronary artery disease.
An example would be a middle age individual with a suspicious chest pain and several known coronary risk factors (like hypertension, diabetes, smoking habit, dyslipidemia, or heredity for CAD, etc.) coupled with other evidence like a suspicious ECG.
Considering your young age and your gender (females are quite protected at similar age from experiencing cardiac ischemia issues), it would not be rational asking a coronary angio CT by a PCP or cardiologist.
This is because in such a young age as your are, it is quite unlikely to have a high overall coronary calcium score (unless you have any important health disorder such as severe chronic renal dysfunction, etc.) or to suffer from coronary artery disease (unless strong heredity, diabetes mellitus type I, a familial homozygous hypercholesterolemia, etc. exist).
Furthermore, coronary angio CT imposes the patient to a high burden of radiation, and for such reasons the risk of radiation should be overcome by the beneficial diagnostic information obtained.
If you don't have a suggestive symptomatology for cardiac ischemia (chest pain on exertion, or recently deteriorating chest pain); if you don't have coronary risk factors (hypertension, diabetes, dyslipidemia, smoking habit, heredity for premature coronary artery disease) or other diseases like severe chronic renal disease, familial homozygous hypercholesterolemia, etc. then coronary artery disease is not scientifically justified and would bring more harms than useful information.
But, if you insist in performing a coronary angio CT, you should evidence about the presence of coronary risk factors (as mentioned above) coupled with a suggestive clinical symptomatology for cardiac ischemia.
On my personal professional opinion, in your case a coronary angio CT would not yield any beneficial diagnostic results.
Instead, it would be more advisable to undergo an exercise cardiac stress test or an Dobutamine stress echo as the harm of radiation is not present.
That's my personal professional opinion.
Please, could you give more clues on why you are thinking to undergo through a coronary angio
CT?
Do you have any specific complaints recently?
What about potential coronary risk factors?
And your recent ECGs??
Hope to have clarified your uncertainties!
I remain at your disposal for further discussions in case you provide me with additional information regarding your suggestive clinical symptomatology and available medical tests.
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I've had continuous chest pain that's gotten worse and worse the past few months especially the last few weeks and I recently went to er for it and had 2 bad ecg's, but no matter those facts they still will not order the test. Is there any other way to get it
Brief Answer:
You may ask a chest CT instead.
Detailed Answer:
Hello again!
If your chest pain is continuous and possibly well localized, modulated by posture changes, by breathing and perhaps by palpation of the affected area, then it is unlikely for that pain to be cardiac related.
In addition, if you don't have any or several of the above mentioned coronary risk factors or any of the above mentioned health issues (severe chronic renal insufficiency, familial homozygous hypercholesterolemia, etc.), then you could not be classified as being on intermediate positive pretest probability and as such the doctors could not classify you for a coronary angio CT (as it would not be helpful, but worthless instead).
Coming to this point, I am sorry to let you know that the medical protocols do not encourage performing coronary angio CT if the above criteria are not met.
You should be glad too, that there is no need to undergo through such a test that utilizes dangerous radiation.
On my opinion, you should insist in having an exercise cardiac stress test, or cardiac stress (Dobutamine) echo.
Regarding potential reasons of your pain, they are supposed to be extra-cardiac (musculoskeletal inflammation, costochondritis, a backbone disorder, a pleural inflammation, etc.). In such case a chest CT (instead of coronary angio CT) would be helpful in exploring potential responsible causes. It may reveal also possible coronary calcifications.
You need to discuss with your attending doctor on the above mentioned issues.
Regards,
Dr. Iliri
You may ask a chest CT instead.
Detailed Answer:
Hello again!
If your chest pain is continuous and possibly well localized, modulated by posture changes, by breathing and perhaps by palpation of the affected area, then it is unlikely for that pain to be cardiac related.
In addition, if you don't have any or several of the above mentioned coronary risk factors or any of the above mentioned health issues (severe chronic renal insufficiency, familial homozygous hypercholesterolemia, etc.), then you could not be classified as being on intermediate positive pretest probability and as such the doctors could not classify you for a coronary angio CT (as it would not be helpful, but worthless instead).
Coming to this point, I am sorry to let you know that the medical protocols do not encourage performing coronary angio CT if the above criteria are not met.
You should be glad too, that there is no need to undergo through such a test that utilizes dangerous radiation.
On my opinion, you should insist in having an exercise cardiac stress test, or cardiac stress (Dobutamine) echo.
Regarding potential reasons of your pain, they are supposed to be extra-cardiac (musculoskeletal inflammation, costochondritis, a backbone disorder, a pleural inflammation, etc.). In such case a chest CT (instead of coronary angio CT) would be helpful in exploring potential responsible causes. It may reveal also possible coronary calcifications.
You need to discuss with your attending doctor on the above mentioned issues.
Regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
What about the bad ecg's?On top of the recent chest pain being worse and the bad ECG I had I'm also worried because I have had a new onset of extreme fatigue everyday. Every afternoon even after a good night's sleep I have this episode of fatigue to where I can't even do daily activities. I had a stress test and a stress echo about a year ago with both normal results but I don't know if those tests are thorough enough or if something could have changed from then to now
Brief Answer:
A cardiac related issue seems quite unlikely.
Detailed Answer:
Hello,
I understand your concern and would like to review those bad ECGs recordings.
If it is possible to upload them here on HCM for a direct review and a second professional opinion.
Also, I would like to have more clues about your chest pain: is it a sharp, stabbing, well-localized or a dull, squeezing, constrictive pain? When and how long does it last?
In what situations (activities, positions, possible treatments, maneuvers, etc.) the pain is exacerbated or relieved?
I would like to review also cardiac stress test and stress echo report (if you could download it here).
Regarding the afternoon fatigue, considering also all your clinical status and cardiac tests results, it doesn’t seem to be cardiac related.
Instead, I would go more in favor of a differential diagnosis between a systemic/inflammatory, metabolic or hormonal disorder.
In such case a close investigation by an internal specialist would be advisable.
As the pain has been present for a long time, meanwhile the cardiac tests have resulted normal, it doesn’t seem that a potential cardiac ischemia could be considered as a new possible feature of your clinical symptomatology.
I personally would try to exclude every possible inflammatory implication (musculoskeletal disorders, costochondritis, backbone disorders, pleura inflammation, etc.
As all the already performed cardiac tests have resulted normal, it is also important to confirm a normal pulmonary function.
In this regards, (1) pulmonary function test and (2) an arterial blood gas analysis would be beneficial.
To conclude I personally don’t believe that an iteration of the already performed cardiac test would bring to a new different conclusion.
At this point, it is necessary to further investigate in different direction for ruling in/out other alternative causes of your complaints.
Wishing all the best!
Regards,
Dr. Iliri
A cardiac related issue seems quite unlikely.
Detailed Answer:
Hello,
I understand your concern and would like to review those bad ECGs recordings.
If it is possible to upload them here on HCM for a direct review and a second professional opinion.
Also, I would like to have more clues about your chest pain: is it a sharp, stabbing, well-localized or a dull, squeezing, constrictive pain? When and how long does it last?
In what situations (activities, positions, possible treatments, maneuvers, etc.) the pain is exacerbated or relieved?
I would like to review also cardiac stress test and stress echo report (if you could download it here).
Regarding the afternoon fatigue, considering also all your clinical status and cardiac tests results, it doesn’t seem to be cardiac related.
Instead, I would go more in favor of a differential diagnosis between a systemic/inflammatory, metabolic or hormonal disorder.
In such case a close investigation by an internal specialist would be advisable.
As the pain has been present for a long time, meanwhile the cardiac tests have resulted normal, it doesn’t seem that a potential cardiac ischemia could be considered as a new possible feature of your clinical symptomatology.
I personally would try to exclude every possible inflammatory implication (musculoskeletal disorders, costochondritis, backbone disorders, pleura inflammation, etc.
As all the already performed cardiac tests have resulted normal, it is also important to confirm a normal pulmonary function.
In this regards, (1) pulmonary function test and (2) an arterial blood gas analysis would be beneficial.
To conclude I personally don’t believe that an iteration of the already performed cardiac test would bring to a new different conclusion.
At this point, it is necessary to further investigate in different direction for ruling in/out other alternative causes of your complaints.
Wishing all the best!
Regards,
Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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