Chapters Transcript Video Office Work Up: Chest Pain Click here to view presentation deck Back to Symposium I'm going to talk to you guys a little bit about uh the work up of, of chest pain in the office. And uh you know what we do, uh We see people in the emergency department a lot of times the um the stem is, is fairly obvious or, or the inclusion of my. But um this is um uh much more subtle and much more difficult as all of you guys know. Um But just I want to cover the the scope of chest pain, um how it impacts uh practice uh in the primary care setting. Of course, uh you guys are the gatekeepers and then um uh also for any uh someone anyone within the cardiology realm that seems sees patients and clinic uh talk about the spectrum of chest pain, the types of chest discomfort. Um and then really dive into the diagnostic approach um in terms of physical exam uh interview, um working up um characterization of the patient. I'm going to review a little bit of the guidelines which I'm sure you guys are aware of the 2021 guidelines, sort of how that uh those updates um uh are applicable to current practice and um dive into some algorithms and pathways. And then ultimately, um you know, what's the right test? Uh So, um just uh a little background here, you know, chest pain uh in the office, there is widely variable, but it's anywhere from, depending on which study you look at 1 to 7% of all encounters. And um that, that correlates uh in the emergency department to about 5% of all encounters. Um in terms of angina, uh sta chronic, stable angina is the most prevalent manifestation of ischemic heart disease that you're going to see in the office in terms of types of chest discomfort. Uh The true ideology is going to be musculoskeletal pain primarily. Again, that's pretty variable, but anywhere from, you know, 25 to 45% of the time, uh that's usually followed by um uh stable angina, uh and then psychogenic disorders and then followed by palm disorders. And uh the spec spectrum of chest pain here um that you see on the left side of the screen is very wide, obviously, uh ra ranging from uh true cardiac chest pain to noncardiac chest pain. So, uh have a lot on our plate and a lot to go through um and a lot to rule out and uh when we're going through our algorithms for the patient and just a reminder, you know, the uh I know I put this on the left here but um chest pain should really be described um based on the 2021 update um as cardiac, possibly cardiac or noncardiac. And I think, um, you know, I, I typically use uh cardiac as typical. I use possibly cardiac as um, you know, somewhere doing a bridge of atypical and uh uh noncardiac, uh the old atypical I should say and then noncardiac being um you know, not related to the heart at all. Um uh cardiac just uh uh as you guys know, a lot of this, of course, um stable angina A CS, um things we won't go too much into in terms of A CS. But um also importantly, um IOA, which I feel like uh doesn't get enough uh attention. Um and uh uh we'll go into that a little bit later on pericarditis and myocarditis, which we have to uh keep a lookout for all the time, of course. And then stress cardiomyopathy, which would be, you know, less common to see in clinic. But um but potential and, and something to, to discuss this is um uh it's hard to read. I know, but this will be the top 10 causes of chest pain. Um This is a valuation in the emergency department and that's by age, that's a weighted percentage. And um you can see the, the blue, uh you know, it's hard to read, but it's a non-specific chest pain type. Um And um uh just gives you a general idea of what's going on there. The, the dark, the blue there on the, the left, the highest one is non-specific chest pain followed typically by either um uh painful respirations, coronary atherosclerosis, something like this. Um uh Then it's bone musculoskeletal abdominal pain. So just a general idea of, of typically how patients present. But the biggest part I think um and the and the most important part for us is what is our diagnostic approach. And I think really building an algorithm is, is important, do the same thing for every patient. And um and I think you will be able to elicit a better idea of what's truly going on, better characterize your patient and uh get them the test they need. And I just broke it up here in terms of uh starting with the history. Um and then further stratify that by onset and duration of the chest discomfort, character of the chest discomfort. I'm not sure if anyone patented the lighter there, but um sorry if they did. But basically, I just think about location, intensity of discomfort. Um And uh when I think of location, I think of location, radiation, intensity of discomfort, description of the chest discomfort and then um remitting factors or um also triggers uh there. Think about the timing and the pattern is really important and associated symptoms um uh that you might have physical exam uh is next. Um you know, that can be helpful. Um But it may not uh give you all the information you need. Um Next, I, I really kind of like to incorporate and correlate and that's just something that I, I think about when I incorporate what I know about the patient's history. So you're looking at all the uh chest x rays, you're looking to make sure they haven't had, you know, uh five rib fractures in the past. Uh you know, you're looking um at their complete uh holistic history and then uh you're also correlating it with um with all the other knowledge that you gained so far about the patient then, um and I'll talk a little bit about this more, but you're going to classify and into buckets uh and sort of maybe try to gently rule things out um based on what you've learned and then uh assess a pret test probability based on uh on the information that you've gathered and using some clinical tools and get a clinical, uh you know, likelihood uh uh ratio or, you know, scenario where, um you know, where does this patient fall in the buckets? And what would be the right test for that patient? Um Don't forget. Um You know, I, I highlighted uh down in red in the bottom there, you know, Angela equivalent. Um You know, this is chest pain, of course. But I think one thing that I probably uh changed over the last several years is, you know, um I, I investigate dysnea I invest investigate a somewhat uh diaphoresis. Um but um uh and also syncope almost as thoroughly as chest discomfort. And I sort of go through the same um diagnostic um regimen for all of those actually. Um just because uh patients can present differently uh depending on the patient. So I think those are extremely important. Um also fatigue as one thing that I didn't put there probably should be number four. The pattern of fatigue is something that is extremely important. And I found lots of true disease um just by the patient coming in with some fatigue. So, um you know, just walking through that general algorithm that I talked about, I think um you know, I start with um you know, when did the, when did the chest discomfort start? Um uh Is it uh a brand new chest discomfort? Um And I, and I'd like to do this before they start telling me about it. And we get into that whole thing until they describe, say, when did this start? And if they say, you know, this has been something that's happening for years, um That also gives me a lot of information potentially. But is this a new chest discomfort? Is this chronic, is this recurrent that I have this before and then it went away and it came back. Um That's all uh extremely helpful um to a certain set of bases for us. Uh Was this a sudden onset chest pain uh versus a gradual onset, um, a gradual onset, you know, you're thinking something where you're having an ischemic disease, potentially. Um, and the same goes for dysnea, uh, of course, as well. Um, and fatigue, it can, you know, kind of, uh, these same things apply to all those symptoms. I also like to uh emphasize any recent illnesses, uh picked up pericarditis a couple of times in the last month and a half or so. Actually, for some of my younger patients coming in with, with chest discomfort that have seen a few people, um you know, uh grabbed AC RP uh but it was uh you know, uh following a recent viral illness. So I think that's uh really important, obviously any injuries or events that they've had. Um And then comparison uh with the previous engine, it can be helpful. Um You know, I, I don't think that's a um you know, uh a winner be all uh type thing. I think that, that some uh sometimes can confuse us but um I think that that is at least helpful. Um Also comparison with any other chest pain they've had is very important. Um New Angela, I just want to say it's not necessarily unstable. Um But it's something uh to note and then uh chronic, stable angina just through this here just uh for the definition that we're going to talk about later. Um The it's a stable s symptom frequency for at least two months that are predictive, uh repetitive and inducible and uh you guys know this. So, um you know, again, kind of breaking down the L ID R um uh algorithm that I talked about earlier in terms of the descriptive um character, you know, I, I use this um but uh typically either um on the, the far left or the far right side, do I sort of um feel um you know, more um uh, more strongly that I'm probably getting the right diagnosis. So, you know, someone comes in with a, with a fleeting very sharp stabbing chest pain that kind of comes and goes for a few seconds. I feel much better. Uh, if someone comes in with a crushing exertional chest discomfort, I feel better. But, uh, there's a big, uh, you know, that's a yellow zone but I think gray zone in the middle that, um, is very, um, um, very hard to tease out sometimes. Um, I think the intensity of discomfort is, uh, can be somewhat helpful. Um, but, um, uh, usually doesn't really help me in terms of figuring out what's going on. Exactly. The descriptive quality is, um, is something that we're going to talk about in a little bit. But it's, uh, you know, you don't want to lead the witness, but I think it's very helpful to, um, to make sure you're getting, you're speaking the same language, uh, literally, uh, in some cases and then, um, triggers and alleviation, which I'll go through a few of those. Just, um, uh, you know, this is again an old, uh typical atypical nonanginal um set up here, but this is just an idea of um, uh types of chest discomfort, um, that people have, um, been qualified as, and their likelihood of having true epicardial coronary disease. Um You see that's broken out for men and women, um just, uh, just an idea and, you know, you can see dysnea there um as well. So, uh obviously age which um uh we all know, but um you know, uh if you can, if you can classify them into cardiac, non noncardiac, possibly cardiac, you're going to give yourself a few percentage points and hopefully getting the right diagnosis in terms of location, just to, to mention a few things. Um you know, any pain localized to a, just a pinpoint area, if they're pointing to one point uh on their body or if they're pointing, um you know, down below the belly button, if they're pointing uh to the hip or below, you know, you can uh probably gonna reduce your uh uh pret probability that it's actually cardiac chest pain. Um You know, just to note that both left and right sided pain. No, I if it's a rights side pain, I take it just as seriously. And there's been some good studies showing um the um the likelihood ratios that um that that's fairly predictive of cardiac chest pain too. So whether it's left or right side of chest pain, um, uh I would take that seriously as potentially true uh uh chest discomfort in everyone, but especially in diabetics. Um, and uh women and elderly patients, um, that's something that would be more likely to occur in association with real chest discomfort. Also, um, think of throat, um, you know, isolated throat, jaw or abdominal pain as representing true cardiac disease. And in that same population, like I said, intensity is not uh often uh extremely helpful. Um The descriptive quality um is uh is more helpful. Um you know, in terms of triggers, just AAA few things that um I, I feel like it helps me tease out the most is that um GD, typically you're gonna have that acid reflux an hour or two after the meal, um during exercise, maybe when you lie down, you're gonna get a lot of things halitosis and these things, maybe some dysphagia. But just, um to, to note there that you really have to stress, um that uh and, and tease out between GED and chest discomfort, you can also get angina after a big meal as well. So, um you know, want to tease out those other things. Is it during exercise? Is it lying down? Um Is it with exertion uh to help you tease those out? A plural um etiology would be usually worse with inspiration cough, um and associated with some sort of cough, viral illness, shortness of breath, costochondritis is, is essentially similar, but maybe it has some tenors to palpation. Um in terms of the timing and pattern, you know, um I, I what I mean here is, uh you know, we talked about onset, this is mostly when it happens and uh what the progression has been. So, just a few notes of um the coronary spasm that should have a circadian pattern. Um you know, uh people don't read the textbook uh always, but, you know, when you get that person who's coming in with some early morning chest discomfort, it occurs at rest, but it sounds fairly uh typical in terms of character. Um I think coronary spasm potentially. Uh again, I mentioned fleeting chest pain last a few seconds is uh usually unrelated um to ischemic heart disease and uh anal symptoms will typically, as I said earlier, gradually, build intensity over a few minutes associated symptoms. This is really uh where I feel uh probably the most uh strongly about. And um I feel like it's helped me tease out uh quite a bit of um of ischemia that I might not have uh discovered earlier in my career. Um But uh typically, um in terms of associated symptoms, you guys know the uh the uh the typical things are shortness of breath, palpitations, diaphoresis, lightheadedness, um uh less typical, but things that are certainly uh possible are presyncope syncope, especially in older patients, any abdominal pain or heartburn, um, that are potentially unrelated to meals or nausea, vomiting, again, that heartburn is a tricky one because you can get GERD, uh, or excuse me, pain after a meal. Um, uh, even and with ischemia. So that's a, sometimes a difficult one to tease out. And, um, uh, the, the part that I think, um, is, is very important is associated symptoms and triggers overlapping. And so I, what I think of here is the, the, you know, the 45 year old female that comes in with anxiety that has a lot of palpitations. And um you know, she's been told four or five times that this is anxiety at the emergency department. Um And, you know, I ask her, OK, that's fine. You have anxiety, you may have panic attacks. Does this feel like your panic attack? Does it feel like your anxiety? And she's like, no, I know that I have those and uh that's unfortunate, but this is completely different, you know, and um and I tell them, you know, it's, it makes sense if you're having chest pain that could drive the anxiety, the anxiety could drive the chest pain, but really teasing those out. So that's one I never ever want to miss and then shortness of breath too. Um you know, in terms of ruling in ischemia, it can be helpful. Uh But I think it's also helpful to, to note a lot of times someone who has um ac OPD exacerbation, something like this teasing out, you know, is that chest discomfort, is that tightness when you feel really short of breath all of a sudden? Do you feel any other chest discomfort when you exert yourself? It's really important, I think to, uh, to tease out those, uh, few things and really discriminating between, between the two. I mentioned, um, a lot of this already but, uh, just to note that, um when you're evaluating the elderly patients, just be on the lookout for those eight, you know, less typical things in terms of uh syncope. Um Also things that I didn't mention uh delirium is a, a potential um presentation in the elderly, any unexplained falls as well. Um Other things and the guidelines, uh we mentioned this, uh uh you know, pretty much already. But um in, in terms of uh women, uh there could potentially also have some um some uh symptoms that are not as typical, potentially. So I may have to do some more digging there. Uh Just some pearls before I go into the next segment, you know. Um I think, you know, you get the um the, the veteran or the farmer that comes in and uh are you having any pain? It's like, oh, definitely not. Um You know, um that's a thing where you make sure that the wife is with them in the, the visit and that's gonna help the diagnosis of course. But um I like to say, ok, well, you don't have pain but what sort of discomfort, any funny feeling at all in your chest? And they're like, well, you know, maybe I actually do. Um, uh, the other thing, um, uh, I, I found is pretty helpful is, uh, don't use sharp and if the patient use sharp, ask what they mean, um, using intense or strong to, to, uh, say, talk about the, uh, the intensity of the discomfort. But uh in terms of characterization, I would say knife like or stabbing something like this to characterize what they mean. Um Like I said earlier, you know, um I always correlate with any prior uh discomfort and confounding conditions like anxiety that I mentioned earlier, any sort of um asthma COPD things like this that might affect their breathing. And um uh also, especially in the diabetic older population, don't ignore any sort of um uh isolated discomforts that I mentioned earlier. Jaw, neck, shoulder, uh tingling in the hand, you know, uh really kind of go into um uh uh your, your algorithm and make sure you're not missing anything there. The intensity of the pain I mentioned a few times is not reliable and then uh any relief with nitroglycerin um is not necessarily diagnostic of uh this cardiac chest pain, even if it's helpful, ac the physical exam. Um I won't go into this too much. Um uh I, I feel like we know a lot of this um I will say, you know, recently I uh picked up on a pericardial friction rub. I, I mentioned some pericarditis recently. Um I was sort of proud of myself, but, um, and happy to write that in the note, but otherwise I think the physical exam can be helpful. Um You know, um I've seen a lot of people come in and, you know, is this reproducible to palpation. And I just put in, if you palpate hard enough, you can always reproduce some pain. Uh They might be so shocked that you hurt them, that they may say. Well, yeah, that, that did hurt and uh you might kind of move on with the um the algorithm but um you know, just uh taking your time, um you uh a lot of this, we um we won't have to cover in depth but the guidelines I wanted to go into a little bit kind of switching gears um and just uh to talk about the focus and, you know, we all um uh knew about the guidelines when they came out and was uh um uh made a lot of press. And um I, I think it's, it's helpful to look back and see where we've come. Have we uh incorporated some of these and um how we're doing and uh just a kind of a reminder as well. Uh Just the guidelines that, you know, just uh reminders that they focused on uh chest pain means, means more than pain in the chest. And essentially um just focusing on Angelo coolness that we've talked about is really uh an important thing to discriminate chest discomfort. Uh A patient centered approach to diag diagnosing and um that includes their, their past um uh history. If they've been uh revascularized before, uh what is their uh current um you know, uh quality of life, things like this uh sharing in the decision making, of course, using clinical decision pathway. So that's in the emergency department and um in the practice in the the clinic as well. So um it has some sort of clinical decision pathway that you can use that helps you discriminate uh assessing accompanying symptoms and then using a risk assessment like we've mentioned as well. Um uh These are uh this is a sort of a dense slide but um you know, a reminder of um of which modalities we should use and what we should probably be focusing on is that um Coronary CT A um should be favored. Um Given that it has a really high negative predictive value in younger patients, patients that are less likely to have obstructive disease. Anyone that's had a an inconclusive um sort of equivocal functional study and stress imaging should be implied uh employed in patients that are older, more likely to have obstructive disease. And then um in those patients, uh maybe that they've had an inconclusive Coronary CT A as well. And then um you know, focusing on and I'll talk about this a little bit but focusing on the entire coronary perfusion system. So you get someone that uh uh Anan and I or maybe have Cath and it was, was clear, maybe some mild disease, they still have just chest discomfort, you know, focusing on the microcirculation thinking um about microvascular disease, uh spasm, things like this and that I know a pathway. Um We don't have this really available everywhere. But um pet um uh over spec is um is something that's been uh emphasized um especially um if you are interested in the microcirculation. Uh MRI gives a lot of good data too in terms of the microcirculation and microvascular dysfunction. But um uh pet if we can get access to it is um is ideal uh incorporation of FFRCT. That's something that's not uh widely adopted um as well, but that's something that's upcoming. Um And in terms of, of who we test and, and what we uh kind of what bucket we stratify them into. I think it's um it's helpful to, to, you know, break into acute staple, chest pain, acute chest pain in the clinic. Um I I do the same thing if you have acute chest pain that's ongoing. Um you get an EKG and send them to the emergency department because whether it is um a sternal fracture or whatever it may be, you know, an X ray, everything's going to be um expedited in that setting. Um, you know, uh, basically EKG get them over to the emergency department essentially unless, um, you know, from your brief history, um, you can elicit something that's, that's clearly noncardiac and the EKG looks nonconcerning. Um, I, I think that's typically the way, um, uh, we should do things, uh, just to note, um, if you have someone that you see that has a history of cabbage, um, and you, you get an EKG not having stemi, they have relatively uh recent onset chest discomfort. Um The guidelines tell us that um uh stress imaging is, is reasonable um to, to get for them or uh according to your CT A to make sure that their graphs are open. Um And um uh also uh you know, kind of uh your kind of dealer's choice. I, I suppose um coronary angiography is, is potentially uh useful as well. So, um it's, it's sort of just an eyeball test of the patient, but both of those things are um are potentially uh helpful. And then uh the guidelines also tell us, you know, anyone with acute chest pain that has that uh you see that was getting chest discovered during or immediately following dialysis or any um sickle cell patients, there was acute onset chest pain transfer, those people immediately to the EDE VA MS. Um So those people I don't mess around with um just looking at um uh sort of we're talking about um what protocols we might use. And what clinical decision making tools. This is the one that I use um uh more recently. And uh sort of asking the question, you have your uh patient that comes in with chest discomfort, no history of coronary artery disease. Um You get the story and uh does this patient need further testing? And uh I use um this um uh um prett test probability kind of scoring here essentially just to, to get a framework. But um you know, the guidelines have, have sort of told us that anyone with low risk of obstructive C ad or pretext probability less than 15% or so can be deferred pretty safely. Um And you know, options there, you could still do an exercise, uh tre uh treadmill test. Um But uh essentially you can defer them uh relatively safely uh with close follow up. And um uh the other thing that, that they mentioned and, and I'm uh I don't see this, you know, widely employed is um is if you do send someone for stre stress testing, uh adding on a coronary artery calcium score with that. Um And that's uh with a stress test, you can also get that independent and that helps their risk stratification, not necessarily their uh you know, talking about their current risk of ischemia. But um uh that's something I haven't seen employed and that's been shown to be helpful long term for the patients, even if that stress test is negative. It's uh it's proven that people that with a normal spec with uh uh you know, for their age and sex and abnormal C AC score, um those people do way worse uh uh down the line. So, um I think that's a pretty important point that I uh put in at this point. Uh just to mention all the, in, in the updated guidelines, all the intermediate and high risk people are kind of lumped into one. And this is the algorithm. So it's, it's a lot of things to go through um that I won't go through in detail. But um you know, the chest pain with no uh coronary artery disease, I think, you know, essentially what I mentioned there, you have your low risk patients and you can do um an ECG stress test, you can uh you can follow them up, you can kind of reassure them and see them again soon. Uh But then I think where it gets more difficult is um is this intermediate to high risk and it's deciding, you know, do we want to coronary CT A? Do we want a stress test? What type of stress test? Um So you, when you make them into that bucket of intermediate to high risk, what do you do then? And then the dreaded, you know, equivocal um stress test or coronary CT A, what do we do then? So um just to break this down a little bit more um in patients with stable chest pain, no coronary disease. Um The, the guidelines tell us that coronary calcium testing is, is reasonable uh for excluding any um calcified plaque that may give them, um um, you know, some sort of indicator that they have a higher risk. Um, something that I don't see, uh you know, employed a lot um necessarily just for those low risk. But um uh and then the exercise trust testing that I mentioned um in terms of anatomical testing, uh intermediate to high risk patients, um you know, coronary CT A is effective. The guidelines tell us. Um uh So we've already gone over and stress testing. Uh you know, it's, it's um for that population is also reasonable and then it just gets into which one do you choose? Um So nothing new that I'm not telling, I'm telling you here that you don't know already. Um the thing that I, you know mentioned earlier was just that um pet is reasonable in preference to spec and that's a two a recommendation now uh to improve the diagnostic accuracy, it is more accurate and um it gives you more information in terms of myocardial blood flow. Um Things like this, if you might be uh concerned for um uh for microvascular angina, for example, um just um uh going on here, um uh any uh intermediate to high risk patients probably get an echo, uh those uh same population as Well, um you know, it's reasonable to send them for um uh uh uh exercise stress test just to see if you can provoke some types of discomfort and, and tease out the, the diagnosis a little bit better, um in terms of sequential or add on testing. Um, you know, um I, I think here we, we've sort of mentioned a lot of this but basically talking about the add on of FFR to uh Coronary CT A. That's not quite uh in full uh uh mainstream yet. But uh that's been shown to be helpful in both the ruling in and ruling out at the far ends of the extreme. Uh But uh the gray zone, folks are a little bit harder to um to quantify just going quickly into the uh this chest pain with, with known coronary artery disease. Essentially. Um If you break that into your non obstructive in your uh obstructive coronary artery disease for your non obstructive disease, uh less than 50% stenosis on a prior CT A or a prior Cath. Uh I think a coronary CT A is something that you can go with. First line if you have some of them that has obstructive C ad. The big thing is intensify their GDMT, their antianginal therapy, uh their uh medical therapy, control their blood pressure um and uh defer testing for them if they have a history of, of high risk C ad in the past left main disease multivessel, still having angina, then you can send them for um invasive NGO um consider a stress test potentially. Um um After that, if, if they're still having discomfort, but no high risk C ad potentially. Um And we've, we've mentioned this already, just the IOA pathway. I would just say that that's uh that's still in flux and that's still pretty difficult to do. Um even in the cardiology realm and we have access to those resources, the, the pet I think is going to come a long way. Right now. We're relying on MRI uh you know, primarily to, to uh find a lot of these patients with microvascular dysfunction. And um uh just wanted to, to mention microvascular Angela. Um That's really hard to, uh you know, I'll uh I'll skip over a lot of this, but um it's really hard to, to diagnose um in a, in the Cath lab setting these days. Um uh We don't have this set up for it in a lot of times. So I think those people, it's really important to stick with it. They're going to get frustrated. You could potentially get frustrated, uh not having a, a definitive diagnosis, but I think it's important to stick with that. And uh studies have shown that, you know, giving a name to that diagnosis and proving it has been shown to be associated with increased um uh medical management, improved medical management of their comorbidities just uh talking quickly about which test. Um uh I think that all depends on the pre-test probability, of course, uh the patient, uh what you have available at your, at your uh facility. Um Obviously, um uh any echo uh MRI avoid radiation. And then if you need myocardial blood flow, we talked about pet and MRI and pet being preferable to spec if you have it available. Um in terms of uh coronary CT A or stress, just the, the two buckets that I look at are 65 or older, you know, younger than 65 lower likelihood of having obstructive C ID. Um Those people, I uh I prefer to get a coronary CT A first, but if they're older than 65 if they have other risk factors, if they might have a scar, if they might have some microvascular dysfunction, um, you know, you might favor a stress test and particularly in the last part, um, a pet or a cardiac MRI potentially. And, um, just to note, um for your coronary CT A, if someone has uh sinus tachycardia all the time, they could have a, a lot of trouble uh getting that uh rate controlled for an appropriate study. So, just something else to think about that we run into quite a bit. Um, the, the last part really that I'll uh hit, um, is, uh, I, I've run into this quite a bit, is managing the coronary CT A results that are uh equivocal or inconclusive. I think essentially if it's inconclusive, um, you know, if you don't get a good result, if they couldn't get the heart rate down, go ahead and stress them. Um, if there's no C AD, I think you're OK, consider the anoca pathway if you have some moderate, mild to moderate, non obstructive C ad. Um I think, um, you could add FFR onto that when it's available or just stress them. So that's pretty, I think, pretty uh reasonable. If you have more um significant uh stenosis, it's more of a judgment call. I think if you have any, you know, significant, more than 50% left main disease, um frequent angina. If you have multivessel, significant disease, I would go to catheterization with that. Um If it's a little on the, uh just above the borderline in terms of constructive C ad, I think you would be OK with stress testing them. Um And that's, that's all I have. Thank you guys. Published November 5, 2024 Created by Related Presenters Brian K. Mitchell, MD Cardiology, Internal Medicine View full profile
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