Is a CT coronary artery scan with FFR calculation indicated for a 44-year-old male with hypertension (HTN), type 2 diabetes, obstructive sleep apnea (OSA), and a body mass index (BMI) of 43.59, who is taking irbesartan (Angiotensin II receptor antagonist) 300mg and amlodipine (Calcium channel blocker) 5mg once daily?

CT Coronary Artery Scan with FFR-CT is NOT Indicated for This Patient

Based on current guidelines, this patient does not meet criteria for CCTA with FFR-CT due to his BMI >35 (43.59), which renders FFR-CT calculation experimental/investigational, and his stable, longstanding symptoms without typical angina do not justify advanced cardiac imaging at this time. 1

Why This Test is Not Appropriate

BMI Limitation for FFR-CT

• FFR-CT is considered experimental and investigational in patients with BMI >35, and this patient has a BMI of 43.59, which significantly impairs image quality and computational accuracy 1, 2, 3
• The technical limitations of FFR-CT in severe obesity include poor signal-to-noise ratio, motion artifacts, and inaccurate computational fluid dynamics modeling 2, 3

Insufficient Clinical Indication for CCTA

• This patient lacks symptoms consistent with chronic coronary syndrome: he has no chest pain, no pressure with exercise, and stable dyspnea for many years that is likely attributable to his severe obesity (BMI 43.59) and obstructive sleep apnea 1
• The 2024 ESC guidelines recommend CCTA only in symptomatic patients with >5% pre-test probability of obstructive CAD, but this patient's dyspnea is stable and longstanding without anginal features 1
• His ASCVD risk of 5.9% is borderline, not intermediate-to-high risk, which would be required to justify advanced imaging in the absence of typical symptoms 1

Exercise Stress Testing is Actually Feasible

• The ordering physician's assertion that he is "not a great candidate for exercise treadmill test" is questionable given that the patient reports he "can play basketball with the kids" 1
• If functional capacity assessment is needed, exercise ECG would be more appropriate as first-line testing given his ability to exercise, and would provide prognostic information at lower cost and without radiation exposure 1

What Should Be Done Instead

Optimize Medical Management First

• Intensify risk factor modification focusing on weight loss (current BMI 43.59), which would address multiple cardiovascular risk factors simultaneously and likely improve his dyspnea 1
• Ensure optimal treatment of his obstructive sleep apnea with CPAP adherence, as untreated OSA significantly increases cardiovascular risk and can cause dyspnea 1
• His blood pressure control appears adequate on irbesartan 300mg plus amlodipine 5mg, but verify target BP of 120-130 mmHg systolic is achieved 1

Address Diabetes Management

• Initiate SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) or GLP-1 receptor agonist (liraglutide or semaglutide) for cardiovascular risk reduction in this patient with type 2 diabetes and multiple cardiovascular risk factors 1
• These agents provide cardiovascular benefit independent of glycemic control and would be appropriate given his risk profile 1

Consider Alternative Diagnostic Approach if Symptoms Worsen

• If typical anginal symptoms develop or dyspnea significantly worsens, then functional imaging (stress echocardiography, SPECT, or PET) would be more appropriate than CCTA given his BMI >35 1
• Exercise stress ECG remains a reasonable first option if symptoms develop, given his demonstrated functional capacity 1
• CCTA without FFR-CT could be considered if weight loss brings BMI <35 and if symptoms suggest low-to-moderate pre-test probability of obstructive CAD 1

Common Pitfalls to Avoid

• Do not order advanced cardiac imaging in asymptomatic or minimally symptomatic patients with obesity-related dyspnea without first optimizing weight, OSA treatment, and medical therapy 1
• Do not assume patients with multiple risk factors automatically need anatomic coronary assessment when symptoms are stable and non-anginal 1
• Do not order FFR-CT in patients with BMI >35, as the results will be unreliable and potentially misleading for clinical decision-making 1, 2, 3
• Recognize that a reassuring ECG in the absence of symptoms does not justify proceeding to advanced imaging 1