This is the angiogram of a 48 year old man who exercises regularly and has no cardiac symptoms. His story is not uncommon. He has a medical up every 2 years including an exercise stress test. He completes 9 minutes of exercise without symptoms but there are some ECG changes and cardiology referral is recommended. The cardiologist agrees the exercise ECG is abnormal and requires further investigation. In the absence of symptoms or risk factors for coronary artery disease a CT coronary angiogram was recommended. This surprisingly to the patient indicated a stenosis in the proximal LAD which was then confirmed with an invasive angiogram. Now the cardiologist and patient are faced with a decision: What to do next?

There are few things cardiologists agree on but I reckon if you showed 10 interventional cardiologist this angiogram they would all say that something must be done. There might be a discussion about the long term pros and cons of drug eluting stents versus surgical revascularisation but most would agree that medical therapy alone in the absence of revascularisation would represent a sub-standard level of care. Most would agree that a 3.5x23mm drug eluting stent could be placed efficiently with very small risk of complication and an excellent result. There would be complete relief of vessel obstruction and at the same time a reduction in patient and physician anxiety.

When it comes to the decision to place a stent are we too strongly influenced by our heart rather than our head. Is it a case of emotion trumping science! The COURAGE  study compared optimal medical therapy with stenting in patients with significant coronary disease. After 7 years of follow up in COURAGE study was there was no significant difference between stent treatment and medication. But what of patients with 90% stenosis in the proximal LAD the so called "widow-maker" lesion. Surely patients with this pattern of coronary disease benefit from revascularisation?

 A recent paper from the COURAGE study looked at just this group of patients and found that there was no significant difference between the patient treated with stents or optimal medical therapy. The figure on the left shows the that the group of patients with >90% stenosis in the proximal LAD did not fair well over the 7 years. The surprising thing is that those treated with angioplasty and bare metal stenting (lowest solid green line) appeared if anything to fair less well than those treated with optimal medical therapy (second lowest green dotted line). The presence of proximal LAD disease as a rationale for favouring stenting was therefore not proven. This finding is provocative and instructive.

 If you ask interventional cardiologists (and this has been done in focus groups) they will acknowledge that stenting offers no reduction in the risk of death or heart attack in patients with stable coronary artery disease but despite this they generally believe that stenting does benefit such patients. One senior cardiologist said to me that he preferred to treat the cause of coronary artery disease with a stent rather than merely manage the symptoms with tablets. Reasons for performing stenting include belief in the benefits of treating ischaemia, the open artery hypothesis, potential regret for not intervening if a cardiac event could be averted, alleviation of patient anxiety and medico-legal concerns. If asked, most cardiologists believe that the oculo-stenotic reflex prevails and all significant and amenable stenosis should receive intervention even in asymptomatic patients.  When cardiologists are challenged about the lack of evidence of adding stenting to optimal medical therapy in preventing future coronary events most still feel that any patient with significant coronary disease should get a stent even whilst acknowledging the evidence. This disconnect between knowledge and behaviour reflects the discordance between cardiologists’ clinical knowledge and their beliefs about the benefits of angioplasty and that non-clinical factors have substantial influence on cardiologists' decision making.

So what happened to this patient? I will leave you to decide and to post your thoughts and comments.

Many patients seek advice from a cardiologist because of palpitations. Sometimes the cause can be worked out from the clinical history and description of the symptoms with a reasonable degree of certainty (e.g. ectopic beats) but often it is necessary to try and correlate the patients symptoms with an ECG recorded at the same time.

Classically this involved fitting the patient with a Holter monitor. These portable devices, named after Norman Holter, American biophysicist, continuously monitoring the electrical activity of the heart. Originally recording onto cassette tape they now use digital technology which has reduced their size. The 24h tape is a useful investigation provided that symptoms occur frequently. However in my experience most patients with palpitations do not have daily symptoms and therefore the value of a short period of recording is low. The other growing use of these devices is to detect asymptomatic arrhythmias such as atrial fibrillation (AF) which is a very common cause of stroke. Detection of episodes of this arrhythmia and offering anticoagulation can dramatically reduce the risk of recurrent stroke. Again a 24h period of recording has limited utility to detect episodes of AF which may occur infrequently. Of course it is possible to record cardiac rhythm for upto 7 days using these monitors or single lead cardiac event recorders such as the Novacor device however these become uncomfortable when worn for long periods of time due to the adhesive electrodes causing skin irritation. Also the electrodes often displace or contact is lost limiting the quality of the recording.

An alternative would be an implantable device to record the ECG. Such a device has existed in the form of the implantable loop recorder also known as a Reveal since 1998. Over the last 14 years the device, which is about the size of a USB stick, has become more sophisticated in terms of algorithms for the detection and assessment of arrhythmia although the size remained the same. However all that is about to change because In the last few days Medtronic have launched the new Reveal LINQ device. 90% smaller than the old one and more sophisticated it occupies a volume of one cubic centimetre and can be inserted through a tiny nick in the skin in with a special applicator. The whole process takes but a moment and yet once in place the device can record the ECG continuously for 3 years and the data can be downloaded to a computer wirelessly and transmitted to the physician for interpretation.

The easy insertion, small size and long battery life put this device centre stage for the management of patients with arrhythmia. If you have paroxysmal AF then using this device to monitor frequency of occurrence and adjust treatment would be very helpful for the doctor and patient since we know that symptoms are not a good guide to  the frequency of arrhythmias. With the advent of Smartphone technology it won't be long before we see implantable devices able to monitor all aspect of a patients physiology and communicate it to doctor and patient.

Reveal LINQ