Does the Potential Overuse of Routine Post PCI Stress Testing and Revascularization Inspire Courage to Embrace More Evidence-Based Decision Making?

Abstract

Among patients with coronary artery disease (CAD), there are widely divergent clinical practice styles in the use of myocardial revascularization, medical therapy, and the assessment of symptomatic or functional status after the initiation of treatment. Frequently, patients who have undergone initial successful revascularization, principally with percutaneous coronary intervention (PCI), are re-evaluated with diagnostic testing (both noninvasive and invasive) within the first year of follow-up, presumably to document objectively the absence of recurrent ischemia, despite the fact that current clinical practice guidelines proscribe such routine testing in otherwise asymptomatic individuals. Clearly, all clinicians seek to achieve optimal care for their patients, but both external pressures from payers and the need to conform to established treatment guidelines often create conflict and uncertainty in physician decision-making regarding what is right. Article see p 11 There should be general agreement that the best outcomes in patients with CAD are observed when comprehensive risk factor modification, intensive medical therapy, and appropriate use of revascularization are used in the setting of judicious clinical decision-making that is evidence based. Optimal medical therapy can be defined as that which uses guideline-directed, disease-modifying interventions (eg, aspirin with or without thienopyridines, statins, and inhibitors of the renin-angiotensin system) as well as therapeutic agents directed toward angina relief and control of ischemia (eg, β-blockers, calcium channel blockers, nitrates, or ranolazine—used alone or in combination).1 For patients with CAD who are symptomatic, antianginal therapy is not considered to be optimal unless at least 2 antianginal agents have been prescribed, and, generally, a desired, favorable treatment effect is achieved in sufficient doses. Similarly, stress testing in the patient with CAD may be performed for evaluation of ischemic symptoms, to assess prognostic risk or, when there is concern that a revascularization procedure has been incomplete, to assess the functional significance of residual obstructive …