0:00

So this is a unique situation,

0:02

which I think you'll all see more

0:04

and more of, especially as CT becomes a primary,

0:07

uh, tool for workup.

0:08

Patient was admitted with mildly elevated troponins,

0:12

but nothing that warranted an immediate urgent cardiac cath.

0:15

So while they were inpatient, they

0:18

decided a CT might be a reasonable option,

0:21

but just based on pretest risk, I think it was mid sixties,

0:25

um, just a mildly elevated troponin value.

0:28

We do capture the calcium score

0:29

and there is some calcium, uh, but nothing terrible.

0:33

And let's see, that was scored at 277.

0:37

So not the worst calcium burden you've ever seen.

0:40

Again, it doesn't matter what the calcium uh, score is,

0:43

it matters that there is any,

0:45

and it's really just a, a way

0:47

to help us kinda assess pretest risk.

0:49

Uh, and as always, we'll start with a left main

0:52

and, hmm, I don't know if I love what I see.

0:55

Know it's very important to look at more than one

0:57

view, which we're about to do.

0:59

Remove that chest wall and show us that left main coming off

1:02

of the, uh, osteum.

1:04

The other thing to remember is on an inpatient

1:09

or anyone with elevated troponin that you know about a lot

1:13

of the kind of management guidance

1:15

that comes from the CAD RADS reporting

1:18

and data system does not apply.

1:20

'cause those are aligned around patients with high certainty

1:24

that they're actually lower intermediate risk.

1:26

So, um, confident diagnosis, uh, and rule outs.

1:29

But once you have troponin values that are elevated,

1:31

you could argue that a small vessel might be missed.

1:33

So our broad strokes read here should be really centered on

1:37

ruling out things like left main or three vessel disease.

1:40

And, uh, probably doesn't take much of an eye test

1:43

to show you here that the left main

1:45

is actually pretty abnormal.

1:46

It's just a MIP to show it's partially calcified.

1:49

It's tight, there's not really a need

1:51

to measure an area you could.

1:53

Um, but already this left main is pretty concerning.

1:55

Just to complete the picture, um,

1:57

I'm gonna show you a dual LAD with a bridge

2:00

and um, I guess I cut that view off for you.

2:03

Uh, you're not gonna get tripped up

2:04

by the intra myocardial bridge,

2:06

and really there's not much in the

2:07

way of stenosis elsewhere.

2:08

Um, and as you come down

2:10

and watch this circumflex here, little motion artifact,

2:14

but not too impressive, uh, I would say

2:18

that's a non-dominant circumflex, but probably mild disease.

2:22

And let's look at the RCA

2:25

and there is a touch narrowing there,

2:27

but there's also some motion.

2:29

Maybe a good way would just be to turn on that,

2:32

bring it into profile, easy to do.

2:38

I could see that maybe getting to moderate

2:40

or perhaps even greater,

2:42

but, uh, the left main still

2:43

to me is the most concerning lesion.

2:45

Um, and actually I can say

2:47

that this is at least moderate in, uh, uh, severity.

2:51

So that would still buy you a cataracts four B.

2:53

Uh, I'm also very curious about the mid RCA,

2:55

so I have at least a, uh, mild and maybe even moderate, uh,

2:58

On the RCA. Let's

2:59

take a look at that invasive angiogram.

3:03

It's important to talk about pretest risk in these cases

3:06

as well, because should you have a negative CTA,

3:08

but elevating troponins further workup might be needed.

3:11

And it could be things other than a, um,

3:13

atherosclerosis, but ooh, wow.

3:15

This is a profound picture when you look

3:19

at that catheter size.

3:20

And the, the vessel is smaller than the catheter.

3:22

Uh, so already this is, uh,

3:26

at least 50% severe left main.

3:29

I'm gonna just read the cath report out loud for you.

3:32

This was considered a 95% osteo stenosis.

3:36

The LED was, um, thought to be 30%.

3:39

Um, so here's the LAD and then the circumflex.

3:44

They called that, uh, second lesion, uh,

3:46

60% proximal disease, um, right around the OM one.

3:51

And then RCA, they kind of corroborated.

3:55

It looked scary in some views to me,

3:58

but it was also thought to be about 30%

4:00

left Main alone though does buy you a trip to the

4:04

or, uh, where the patient went and got a cabbage

4:09

because there's so much myocardium at risk

4:11

and the risk of a stent going down,

4:13

that's the preferred treatment for left main disease.

4:16

So if you remember only one thing from this course,

4:20

remember, don't miss left main disease if you can help it.

4:22

Uh, remember that not all cases will be

4:25

as obvious on axials like this.

4:26

So sometimes they may be more

4:27

of a vertically oriented lesion.

4:29

And if you have any doubt, you could go back

4:32

and, and measure an area.

4:33

You don't need a ruler though to see.

4:35

That's pretty narrowed.

4:36

And I see a lot of plaques surrounding the, uh, vessel.

4:38

So a higher risk situation, cataracts four B,

4:42

left main disease.