In a recent social media post, cardiologist Dr. Kaustubh Bondre shared a concerning trend: patients demanding advanced heart scans based on information from podcasts, not medical necessity. He described an asymptomatic patient who, despite having completely normal ECG and stress test results, insisted on undergoing a CT Coronary Angiography because he had "seen it on a podcast." This case, Dr. Bondre explained, was driven by fear rather than clinical need, sparking an important conversation about the appropriate use of diagnostic technology in heart care.
The Foundation: What ECG and Stress Tests Really Tell Us
To understand why advanced scans aren't always the first step, it's crucial to know what initial tests reveal. An Electrocardiogram (ECG) records the heart's electrical activity, helping doctors spot irregular rhythms, blockages, or signs of past damage. A normal ECG is a strong indicator that many urgent heart conditions can be ruled out.
A stress test takes this further by monitoring the heart under physical strain, either through exercise on a treadmill or with medication that mimics exercise. It looks for signs of reduced blood flow (ischemia). When both these tests return normal results for a stable patient, they predict a very low risk of major cardiac events—often less than 1% per year.
However, these tests have limits. They assess heart function under pressure but do not visualize the coronary arteries directly. A stress ECG can miss 10-20% of significant artery blockages, including non-obstructive plaque that could cause future problems. Research indicates that atherosclerosis (plaque buildup) is present in about 50% of people who show no symptoms during a stress test.
CT Angiography: Powerful Tool with Significant Downsides
Computed Tomography Angiography (CT Angio) is a sophisticated imaging technique. It uses a CT scanner and a contrast dye injected into the bloodstream to create detailed 3D images of the coronary arteries. It can detect narrowing of more than 50% with about 96% accuracy and reveals the type and amount of plaque, guiding treatment like statin therapy.
Despite its power, CT Angio carries notable risks that make it unsuitable as a routine screening tool. The procedure involves significant radiation exposure—equivalent to 100 to 600 chest X-rays (5-15 millisieverts). This exposure elevates lifetime cancer risk, with breast cancer being a particular concern for women (approximately 1 in 1,000). The contrast dye can cause allergic reactions or kidney damage, especially in patients with pre-existing conditions.
Furthermore, the test can lead to unnecessary procedures. It has a false-positive rate, meaning it can suggest a blockage that isn't critically significant. This can result in patients undergoing an invasive cardiac catheterization for confirmation, a procedure that research shows yields negative results in 40-60% of cases when prompted by a CT Angio finding.
When is CT Angiography Actually Recommended?
Medical guidelines from bodies like the American College of Cardiology are clear. For patients with stable chest pain, the first step should be a functional test like a stress test. CT Angio is recommended as a next step only in specific scenarios.
It becomes valuable for patients at intermediate or high risk. This includes individuals with atypical chest pain, an abnormal ECG, diabetes, a strong family history of early heart disease, or men over 50 and women over 60 with multiple risk factors. It is also highly useful when stress test results are unclear or contradictory, as it can non-invasively confirm or rule out blockages.
The test has a superb 94-99% negative predictive value, meaning if it shows no disease, doctors can be almost certain coronary artery disease is absent without resorting to catheterization. It also plays a role in pre-surgical evaluation for non-cardiac surgeries and for patients with persistent symptoms despite normal stress tests.
Striking the Right Balance for Heart Health
The key takeaway from Dr. Bondre's insight is the importance of balanced, evidence-based decision-making. For a low-risk, asymptomatic individual with normal ECG and stress tests, a CT Angio exposes them to radiation, cost, and potential complications without improving their outcome. Large studies like the PROMISE trial have shown that for stable patients, starting with CT Angio offers no advantage over stress testing in preventing heart events but leads to more invasive follow-up tests.
The most effective approach is a shared decision between doctor and patient, considering pretest probability, age, and personal preference. Ultimately, lifestyle modifications—a heart-healthy diet, regular physical activity, weight management, and quitting smoking—provide far superior long-term prevention than any scan for the majority of people. Chasing advanced diagnostics out of fear, as seen in the podcast-inspired case, can often do more harm than good.
