Cardiac case meeting: screening the asymptomatic patient, soft plaque, CABG headaches & post-PCI duals
QCG interactive case of Mr BS (Ben), 47 — calcium 342, LDL >5, probable FH, stress-echo ischaemia, double-vessel bypass, then graft PCI and femoral pseudoaneurysm. Imaging, surgery and interventional pearls for GPs.
- Case presenter / chair
- Alex (QCG; referred to by name by Charles Chow) — walks the Mr BS case from GP referral through bypass, sepsis and later graft PCI.
- Cardiac CT
- Dr Charles Chow — calcium score vs CTCA, plaque morphology, who to image.
- Interventional cardiology
- Maggie (surname unclear on ASR; recently back from the UK) — left-main discussion with surgeons; post-PCI complications, radial vs femoral, DAPT/triple therapy.
- Cardiology panel
- Jeff Franco — functional testing to document ischaemia before revascularisation; calcium risk is linear (~300 already high risk).
- Cardiac surgery
- Marshall Lachlan (newer-generation surgeon; also St Andrews); Andrew Mulligan / Andrew Clark (“Clarkie”) — post-op AF, pleural/pericardial effusions, PE, sternal wounds, anticoagulation after CABG.
- Session context
- Otter id
srV76iQ92ZUatMlHkWIGJ3E2kVA· title Cardiac Case Presentation Meeting · ~58 min (3479 s) · focus: asymptomatic coronary screening → revascularisation → early post-op → risk-factor control. Companion lipid talk: cholesterol-management.
Key messages for GPs
- Young patient + calcium ≫90th centile + LDL >5 + premature family CAD → treat as high risk; Dutch Lipid Clinic Network style scoring often lands “probable FH” before genetics.
- Australian absolute CVD tools stay first-line; calcium (>99 or >75th centile) and family history can up-classify risk one step (or more).
- Calcium score measures calcified burden only — misses soft plaque. Ben’s left main calcium was 0 and circumflex 2.8 with critical stenoses on angio.
- Panel lean: document ischaemia with a functional test before elective revascularisation in this phenotype; CTCA if stress imaging is normal but suspicion stays high.
- After CABG: AF is common; pleural fluid after coronary surgery often needs drainage at a cardiac centre; midline sternal drainage or a wound going backwards → early surgical review.
- After PCI: prefer radial when possible; femoral still needed for grafts. Protect DAPT (especially month 1); call before stopping; minimise triple therapy duration with DOAC.
Meet Ben (Mr BS)
True initials. 47-year-old police officer (ex-pharma). GP referral for cardiac assessment: significant dyslipidaemia and CT coronary calcium. Parameters supplied: BP 131/90; prior calcium 94, then 342.5; total cholesterol ~8, LDL >5; no allergies, no medicines. Calcium predominantly in the LAD — well above the 90th percentile for age.
Absolute risk, FH and statin refusal
Without calcium, five-year absolute risk calculated ~3%. Updated Australian CVD guidelines (National Heart Foundation / CVD risk pathway) allow up- or down-classification using calcium, socioeconomic factors, AF, ethnicity and more. Calcium ≥100 (talk also cites >99) or >75th centile pushes intermediate → higher risk. Family history box ticked.
First words in clinic: he “knows the conspiracy with the statins” and will not take one. Father MI at 53; paternal grandfather at 47. With LDL >5 (+3 Dutch points), premature family disease (+1) and premature CAD on imaging, he sits in a probable FH band before anyone orders a gene panel — relevant later for PCSK9 access pathways.
Bravado and conspiracy beliefs at first visit → anxiety, missed rehab and stalled lipids after surgery. The case is as much behavioural medicine as plumbing.
Calcium score vs CTCA
Charles Chow: conventional risk calculators estimate probability of events, not disease. Most infarctions still occur in low–intermediate calculated-risk people. Imaging reclassifies.
- Calcium score — direct measure of calcified plaque burden; black-and-white Agatston number + age percentile. Zero often allows statin deferral in selected patients (still modify by age/history). ≥100 generally supports therapy (age-modified). Does not see soft plaque, inflammation or stenosis severity.
- CTCA — lumen + non-calcified plaque; stenosis; high-risk morphology (low attenuation / necrotic core, positive remodelling, spotty calcium, napkin-ring). Emerging: peri-vascular fat attenuation (inflammation), FFR-CT, quantitative soft-plaque volume tracking.
Who to refer: intermediate risk needing reclassification; strong family history despite “normal” traditional factors; younger patients wanting clarity; symptoms not explained by other tests. Start with the risk tool, then choose calcium ± CTCA to target prevention earlier.
Functional testing → angiogram → CABG
Andrew (surgical voice) and Jeff: many patients deny symptoms; functional testing asks whether disease is causing ischaemia. Options: exercise ECG, stress echo, dobutamine stress echo, perfusion scan. Jeff: calcium risk is roughly linear — ~300 already high risk, not only “over 400”. To revascularise you need documented ischaemia in this framing.
Ordered test: stress echo — 10.8 METs, normal heart size, EF 60%, electrically positive, new wall-motion abnormalities → LAD territory ischaemia. Angiogram: significant left main, critical proximal LAD, critical mid circumflex; RCA large with milder disease. Maggie: with left main, discuss surgery first (would have stented LAD + circ alone). Ben: double-vessel bypass — LIMA → LAD; left radial → OM2.
Post-bypass: AF, fluid, sternal sepsis
Day 2 AF → reverted 24–48 h on sotalol. Mild–moderate left pleural effusion — asymptomatic, conservative. Discharge: aspirin + statin (finally); cardiac rehab strongly advised; repeat CXR for effusion. Then sternal sepsis — washout and staged closure by covering surgeon while operator on leave; otherwise good recovery.
Surgeons’ GP-facing tips:
- AF — very common (higher after valves). Often amiodarone ~6 weeks then stop if sinus; ± beta-blocker/digoxin; sotalol ↔ QT caution. Single brief self-terminating episode may not need anticoagulation; in-and-out AF usually does — DOAC for coronaries increasingly preferred; warfarin still for higher pericardial-effusion-risk cases (ASD, some valves).
- Pleural effusion — after CABG often a small bloody component that worsens with “watchful waiting”; drain to dryness at a cardiac centre (IR does this daily). Valve-only sympathetic/HF effusions may diurese.
- Pericardial effusion — uncommon after straightforward CABG; more after valves/ASD/roots. Comparison CXR + CT helps.
- Acute breathlessness — CT can show pleural + pericardial fluid + PE together; anticoagulate and keep cardiac team involved.
- Sternal wounds — dressings with glue may stay on early; wound going backwards needs early review — IV antibiotics and/or washout (± pec flaps). Drain-hole ooze OK; midline drainage is not. Happy to see same day, 7 days/week.
Twelve months later: adherence & graft PCI
Difficult patient: resists statin uptitration from 10 → 20 mg (side-effect complaints ± nocebo), uncertain ezetimibe/aspirin adherence, no cardiac rehab. Lipids barely move (TC 6.1 / LDL 3.7 → later TC 7 / LDL 4.2). Returns with exertional chest tightness. Stress echo mild; CTCA: possible severe left main stenosis, occluded proximal LAD with patent LIMA, radial-graft stenosis to OM2, RCA still milder. Stent to radial graft via right femoral (left radial used as conduit; LIMA under left clavicle). Femoral pseudoaneurysm → ultrasound-guided thrombin injection. Needs aspirin + clopidogrel 12 months — unhappy again; still refuses rehab.
Post-PCI care & DAPT
Maggie: diagnostic angio risk <1% but not zero (vascular, AKI, contrast allergy, arrhythmia, rare stroke/MI). PCI adds peri-procedural risks; most adverse events are early, but delayed issues present to GPs — stent thrombosis, access-site bleeding, systemic bleed on antiplatelets.
| Access | GP-relevant points |
|---|---|
| Radial (default ~80–90%) | Less major bleeding; walk early; can still get (rarer) pseudoaneurysm |
| Femoral | Needed for grafts / large-bore / radial fail; flat bed rest; retroperitoneal bleed risk |
- Pseudoaneurysm: expanding painful swelling, thrill, pulsatile mass, limb ischaemia → duplex. Thrombin for small necks; surgery if large.
- Retroperitoneal bleed red flags: back/flank pain, hypotension, falling Hb, little groin swelling → ED now.
- Recurrent ischaemic pain → ECG ± compare to old tracing; syncope/arrhythmia symptoms; check renal function in CKD up to ~1 week post.
- DAPT: aspirin + clopidogrel or ticagrelor. Stable/CCS ~6 months (ESC/HA framing in talk); ACS ~12 months; shorter in select low thrombotic risk — evolving trials. Do not stop in first month (ideally first 3) without cardiology advice.
- Triple therapy with OAC: minimise — often ~1 week triple → dual (usually DOAC + clopidogrel) for 6–12 months → OAC alone. Prefer clopidogrel over aspirin when combining with DOAC (lower bleed).
Maggie (and colleagues) want the call if the regimen is confusing. PCI reports should state indication, agent, intended stop date and any triple-therapy plan — if missing, phone or email.
Clinic checklist
- Young high calcium + LDL >5 + premature family CAD → high risk / probable FH pathway.
- Do not treat calcium 0 in one vessel as “no soft plaque”.
- Match test to question: disease burden (calcium/CTCA) vs ischaemia (stress imaging) vs anatomy for revascularisation (invasive angio/CTCA).
- Post-CABG: AF plan, drain stubborn pleural fluid at a cardiac centre, escalate sternal concerns early.
- Post-PCI: protect DAPT; examine both groins and wrists; never guess triple-therapy swaps.