The paper of Koch and colleagues in this issue takes advantage of a situation that is still commonplace in Holland but becomes quite rare in the rest of the world.1 Every year, thousands of Dutch patients are referred to invasive cardiac centres licensed to dilate by invasive cardiac centres barred from dilating by government ruling. Combining the therapeutic with the diagnostic act makes sense, is cost efficient, and patient friendly. It remains a taboo for the majority of Dutch invasive cardiologists working in so called diagnostic centres. While it is a taboo by legislation for them, it is a taboo by solidarity for their colleagues working in the few so called therapeutic centres. If they were combining the diagnostic angiogram with the coronary angioplasty in all their patients, their market advantage over their purely diagnostic colleagues would be so conspicuous that the usual competition between cardiac care providers would capsize for sure. The primary idea behind this system is to boost the quality of coronary angioplasty by having a large number of procedures performed in a small number of centres. Secondary ideas behind it are the cost concern that too many centres for cardiac surgery would be run just to chaperone the respective interventional cardiology activities and a certain desire to contain angioplasty numbers by setting up a road block on the way to the procedure.

A great majority of patients of the tertiary cardiac centre presenting their report on preselection of coronary angioplasty patients for short term observation1 were referred with a neat history, physical examination, and coronary angiogram from an invasive but non-interventional cardiac centre in the catchment area. About 90% of them subsequently underwent single vessel angioplasty which is in keeping with a contemporary European database.2 After stratifying them into those presumably not meaning …