I know an old lady...

Do you remember the children's song "I know an old lady who swallowed a fly?" She swallowed a spider to catch the fly, then a bird to catch the spider, she swallowed a cat to catch the bird etc. Eventually she swallowed a horse - and as the song goes "She dead of course!"

This song reminded me of a recent patient. A middle aged man with no medical problems, normal blood pressure and a cholesterol of 5.4. He happened to have the "good fortune" of being sent for a routine executive medical. The ECG was abnormal showing left axis deviation and a Q wave in lead V2. The ECG report suggested cardiology referral and recommended an echocardiogram. The echocardiogram showed possible septal hypokinesia with good LV function and normal valves. The echo led to a CT coronary angiogram which showed a normal left coronary and a 50% stenosis in the mid right coronary artery. The CT led to an exercise ECG which showed 1mm ST depression infero-laterally at 6 minutes of exercise. The exercise ECG led to an invasive angiogram which showed a moderate mid right coronary stenosis. The angiogram led to FFR measurement of the lesion with a FFR at maximum hyperaemia of 0.74. The FFR led to a coronary stent being implanted and the prescription of dual antiplatelet therapy, ACE inhibitors, intensive statins and beta blockers. The patient was asymptomatic physically but anxious. How would he know if coronary disease were to occur in the future, when should he arrange another angiogram?
It seems that one thing leads to another. One test leads to the next and then the next and so on. The patient had evidence of coronary disease and it was demonstrated to be flow limiting so according to the best evidence from the studies it is possible to justify all the steps that were taken. Has all of this testing resulted in an improvement in the patient's health, is the risk of death, myocardial infarction or need for urgent revascularisation reduced. Will there be unwanted effects of the drugs being used. Did the patient really benefit from stent insertion especially as he had never had any symptoms of chest pain?
When people have health screening it is very important that they understand what the possible outcomes of doing these investigations.

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