We read with great interest the recent article by Bhattacharyya et.
al.1 They state that a high proportion (71/250) of stress echocardiograms
(SE) were performed on low risk patients and were inappropriate,
concluding that implementation of diagnostic appropriateness criteria2
would reduce this.
Appropriateness criteria2 published in 2011 reviewed clinical
scenarios warranting SE and graded these on a scale of 1 to 9. Classifying
patients into 3 categories, appropriate (grade 7-9), uncertain (grade 4-6)
and inappropriate (grade 1-3). The 2013 ECS guidelines3 for investigation
of stable coronary artery disease (CAD) recommends functional testing for
patients with intermediate (15-85%) pre-test probability (PTP). However,
Bhattacharyya et. al. do not elaborate on the PTP of patients in each
classification. Thus, in accordance with new ESC guideline SE may have
been appropriate in some of the patients classified as uncertain or
inappropriate.
Furthermore, a proportion of patients classified as inappropriate
included previously revascularised patients with stable symptoms.
Cardiologists may feel obliged to perform investigations on symptomatic
previously revascularised patients, often with invasive coronary
angiography, even if they are stable with a negative SE within the
previous two years. To reduce the burden on SE, cardiac CT is a viable
alternative that demonstrates grafts and proximal stent patency.
Finally, NICE, ESC and ACC/AHA guidelines all differ in diagnostic
guidelines, enabling cardiologists to use their experience and local
expertise to select the most appropriate investigation for individual
patients.
Conflict of Interest:
None declared
We read with great interest the recent article by Bhattacharyya et. al.1 They state that a high proportion (71/250) of stress echocardiograms (SE) were performed on low risk patients and were inappropriate, concluding that implementation of diagnostic appropriateness criteria2 would reduce this.
Appropriateness criteria2 published in 2011 reviewed clinical scenarios warranting SE and graded these on a scale of 1 to 9. Classifying patients into 3 categories, appropriate (grade 7-9), uncertain (grade 4-6) and inappropriate (grade 1-3). The 2013 ECS guidelines3 for investigation of stable coronary artery disease (CAD) recommends functional testing for patients with intermediate (15-85%) pre-test probability (PTP). However, Bhattacharyya et. al. do not elaborate on the PTP of patients in each classification. Thus, in accordance with new ESC guideline SE may have been appropriate in some of the patients classified as uncertain or inappropriate.
Furthermore, a proportion of patients classified as inappropriate included previously revascularised patients with stable symptoms. Cardiologists may feel obliged to perform investigations on symptomatic previously revascularised patients, often with invasive coronary angiography, even if they are stable with a negative SE within the previous two years. To reduce the burden on SE, cardiac CT is a viable alternative that demonstrates grafts and proximal stent patency.
Finally, NICE, ESC and ACC/AHA guidelines all differ in diagnostic guidelines, enabling cardiologists to use their experience and local expertise to select the most appropriate investigation for individual patients.
Conflict of Interest:
None declared