A 52-year old woman with atypical chest pain ended up with a heart transplant after a CT angiogram to “reassure” her sparked a devastating sequence of events. Following a false-positive CT angiogram, the patient underwent coronary angiography and suffered a dissection of the left main coronary artery, followed by emergency CABG, subsequent graft failure, and multiple additional complications. The case report from the Cleveland Clinic is published online in the Archives of Internal Medicine.

“We believe that in this case the unwarranted use of advanced diagnostic imaging (false-positive CCTA findings) directly contributed to unnecessary cardiac catheterization that resulted in a tragic complication and significant morbidity,” write the authors. “In an era in which comparative efficacy of therapies has assumed critical importance, the unchecked growth of CCTA seems not only unfounded but also irresponsible and unsustainable.”

In an accompanying editorialArchives editor Rita Redberg and colleagues write that the case is another illustration that “less is more … if a test is not sufficiently accurate to change clinical management in a particular setting, it should not be done.”

This post is republished with permission from CardioExchange, a new website for cardiovascular healthcare professionals from the New England Journal of Medicine. CardioBrief readers who are healthcare professionals are invited to join the site.

4 Comments

  1. It is irresponsible foe the authors to lay blame for this unfortunate series of events on Coronary CTA. Why not criticize the operator that caused the left main dissection. Certainly false positives occur with myocardial perfusion studies. It is disingenuous and blatant sensationalism to uses this case as an example of CCTA.
    Given a similar clinical scenario thevauthors, assuming they still are involved in caring directly for patient may have taken a similar course. A bad clinical outcome is usually multifactorial, not avresult of a diagnostic study

  2. A)When a women presents with atypical chest pain,one have to remember:
    Women,cardiac diseases,have atypical presentation
    B)Atypical Chest pain can be anything among:
    Cardiac,Pulmonary,G.I.,Musculoskeletal
    What should be the first step,if not critical?Nitro-glycerin of course.
    Second:Stat H.D.L.(and cardiac enzymes).
    Why H.D.L.?Because it is the BEST(Negative)marker of any disease.
    Then what?NiacinIR(Immediate Release),
    Sublingual.Why?It is the best vasodilator and spasmolytic existing.
    When chest pain resolves,esophageal spasm gone,reflux gone,pulmonary hypertension eases down,no hypertesion:The patient is at ease,and the doctor is at ease.
    Do not cathterize someone with LOW H.D.L.,why?
    The blood vessel’s wall are feriable.He/She will dissect.

    1. niacin, HDL are interesting diagnostic and therapeutic choices, but I don’t think it is mainstream enough to be defensible. Witholding cath due to HDL is news to me. and a spasmolytic and vasodilator combined effect may resolve pain, but still doesn’t dx etiology. l have a low threshold to admit any pain with real risk factors. Seen too many atypicals rule in and/or have a bad outcome

  3. This ridiculous “report” in Archives by a known detractor of CT (Nissen) was accepted and editorialized by Redberg (another detractor) simply because it was thought to be an opportunity to criticize CT angiogram. It is interesting that the majority of >75 posters in theheart.org were outraged by the Archives false and dangerous depiction of an obese, untreated hypertensive woman with chest pain as such low risk that “simple re-assurance” was all that is necessary—no further diagnostic procedures (stress testing or CT). Interestingly, not only was her pre-test likelihood “intermediate” but her CTA revealed extensive atherosclerosis which would have led to aggressive “secondary guidelines” type therapy. Nobody bought the idea that her cath was necessary….so the case is about an unnecessary CATH, not a “just in case” CTA, a procedure that is part of the standard algorithm of a symptomatic patient at intermediate risk. Redberg’s dangerous advice, if applied broadly would leave 1000s of women with ischemia and non-obstructive atherosclerosis UNDETECTED—that is scary.

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