Glagov’s phenomenon and limitations of coronary CT angiography in asymptomatic 65 year male with severely elevated Agatston score: Case report and literature review

Noninvasive identification of patients with coronary artery disease (CAD) remains a clinical challenge despite the widespread use, and possible overuse, of imaging and provocative testing; more than 50% of patients currently referred to coronary angiography show normal or non-obstructive CAD.

Evaluation of coronary artery disease (CAD) using coronary computed tomography angiography (CTA) has seen a paradigm shift in the last decade. Evidence increasingly supports the clinical utility of CTA across various stages of CAD, from the detection of early subclinical disease to the assessment of acute chest pain. Additionally, CTA can be used to noninvasively quantify plaque burden and identify high-risk plaque, aiding in diagnosis, prognosis, and treatment. 

Coronary artery calcium (CAC) is a highly specific feature of coronary atherosclerosis. CAC scoring has emerged as a widely available, consistent, and reproducible means of assessing risk for major cardiovascular outcomes. Glagov’s phenomenon of arterial wall remodeling and numerous limitations in the technique of CTA may pose hinderances in the correct estimation of obstructive CAD in severely and very highly elevated Agatston score.

Recently, the 2-dimensional Speckle Tracking Echocardiography (STE) has gained substantial clinical interest. Left ventricular longitudinal strain, derived using two-dimensional speckle-tracking echocardiography, has emerged as a noninvasive marker of both global and regional LV dysfunction in patients at risk for developing CAD. Current evidence supports the use of global longitudinal strain (GLS) in the detection of moderate to severe obstructive CAD in symptomatic patients. GLS may complement existing diagnostic algorithms and act as an early adjunctive marker of cardiac ischemia.

Here, we are presenting a 65 year old asymptomatic male with a normal 2Dimensional echocardiography and negative treadmill stress test (TST) during a routine health check up. The patient requested for CTA which demonstrated severely elevated calcium score of 468 Agatston units accompanied by extensive triple vessel disease. These non-invasive tests were conducted at a local corporate hospital and their cardiology consultants suggested either a multivessel percutaneous coronary intervention (PCI) with stenting or triple vessel coronary artery bypass grafting (CABG). Hence, the patient visited our centre to obtain a definitive opinion regarding revascularization.