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Enhanced Education for Noninvasive Cardiac Testing

Enhanced Education for Noninvasive Cardiac Testing To the Editor In their Teachable Moment in a recent issue of JAMA Internal Medicine,1 Schmidt et al describe a case of a man in his late 60s with dyspnea on exertion referred for 3–vessel coronary artery bypass grafting surgery following a normal exercise stress echocardiogram due to overdiagnosis by coronary computed tomography angiography (CCTA) and cardiac catheterization. The authors correctly highlight 2 teachable moments: (1) the patient’s symptoms were unlikely to be from flow–limiting coronary artery disease (CAD); and (2) the patient should have been counselled about the role of medical therapy. However, the failure in this case was not because of the CCTA test, but rather because of how the treating physicians acted on the results of the test. We agree that the patient would have benefited from medical therapy for CAD, especially given the fact that his testing presumably revealed an extensive amount of CAD.2 However, in most patients who have obstructive CAD, functional testing is advised to determine if there is a role for further invasive testing or coronary revascularization.3 In this case, the normal stress echocardiogram should have been used to implement medical therapy for CAD and perhaps signify the need to assess for other etiologies of dyspnea. Any test result, if not ordered in the right clinical context or interpreted and/or acted on correctly, can promote overdiagnosis and corresponding subsequent consequences. In addition to patient preferences, astute clinicians must be aware of the strengths and limitations of all tests in clinical management, as well as how to best integrate the results of all available tests. Our group2 and others4 have shown that CCTA has been associated with a beneficial impact on patient management by implementing therapies such as aspirin and statins. Indeed, this is one of the potential advantages of detecting CAD (if it would otherwise not have been diagnosed), because the intensification of medical therapies may lead to a lower rate of incident myocardial infarction.5 While we acknowledge that there is a potential for overuse of coronary revascularization when coronary anatomy alone is used for medical decision making, this limitation should serve as a need to educate physicians on how to use the results of coronary computed tomography angiography rather than to label this test as one which leads to overdiagnosis. Cases like this Teachable Moment by Schmidt et al1 highlight the growing need for greater collaboration between general internists, cardiologists, and imaging specialists to enhance education for all health care providers who order noninvasive cardiac testing. Back to top Article Information Corresponding Author: Ron Blankstein, MD, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115 (rblankstein@partners.org). Conflict of Interest Disclosures: None reported. References 1. Schmidt T, Maag R, Foy AJ. Overdiagnosis of coronary artery disease detected by coronary computed tomography angiography: a teachable moment. JAMA Intern Med. 2016;176(12):1747-1748.PubMedGoogle ScholarCrossref 2. Hulten E, Bittencourt MS, Singh A, et al. Coronary artery disease detected by coronary computed tomographic angiography is associated with intensification of preventive medical therapy and lower low-density lipoprotein cholesterol. Circ Cardiovasc Imaging. 2014;7(4):629-638.PubMedGoogle ScholarCrossref 3. Cury RC, Abbara S, Achenbach S, et al; Endorsed by the American College of Cardiology. CAD-RADS(TM) coronary artery disease—reporting and data system: an expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr. 2016;10(4):269-281.PubMedGoogle ScholarCrossref 4. Ladapo JA, Hoffmann U, Lee KL, et al. Changes in medical therapy and lifestyle after anatomical or functional testing for coronary artery disease. J Am Heart Assoc. 2016;5(10):e003807.PubMedGoogle ScholarCrossref 5. Bittencourt MS, Hulten EA, Murthy VL, et al. Clinical outcomes after evaluation of stable chest pain by coronary computed tomographic angiography versus usual care: a meta-analysis. Circ Cardiovasc Imaging. 2016;9(4):e004419.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Enhanced Education for Noninvasive Cardiac Testing

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Publisher
American Medical Association
Copyright
Copyright © 2017 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2017.0768
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Abstract

To the Editor In their Teachable Moment in a recent issue of JAMA Internal Medicine,1 Schmidt et al describe a case of a man in his late 60s with dyspnea on exertion referred for 3–vessel coronary artery bypass grafting surgery following a normal exercise stress echocardiogram due to overdiagnosis by coronary computed tomography angiography (CCTA) and cardiac catheterization. The authors correctly highlight 2 teachable moments: (1) the patient’s symptoms were unlikely to be from flow–limiting coronary artery disease (CAD); and (2) the patient should have been counselled about the role of medical therapy. However, the failure in this case was not because of the CCTA test, but rather because of how the treating physicians acted on the results of the test. We agree that the patient would have benefited from medical therapy for CAD, especially given the fact that his testing presumably revealed an extensive amount of CAD.2 However, in most patients who have obstructive CAD, functional testing is advised to determine if there is a role for further invasive testing or coronary revascularization.3 In this case, the normal stress echocardiogram should have been used to implement medical therapy for CAD and perhaps signify the need to assess for other etiologies of dyspnea. Any test result, if not ordered in the right clinical context or interpreted and/or acted on correctly, can promote overdiagnosis and corresponding subsequent consequences. In addition to patient preferences, astute clinicians must be aware of the strengths and limitations of all tests in clinical management, as well as how to best integrate the results of all available tests. Our group2 and others4 have shown that CCTA has been associated with a beneficial impact on patient management by implementing therapies such as aspirin and statins. Indeed, this is one of the potential advantages of detecting CAD (if it would otherwise not have been diagnosed), because the intensification of medical therapies may lead to a lower rate of incident myocardial infarction.5 While we acknowledge that there is a potential for overuse of coronary revascularization when coronary anatomy alone is used for medical decision making, this limitation should serve as a need to educate physicians on how to use the results of coronary computed tomography angiography rather than to label this test as one which leads to overdiagnosis. Cases like this Teachable Moment by Schmidt et al1 highlight the growing need for greater collaboration between general internists, cardiologists, and imaging specialists to enhance education for all health care providers who order noninvasive cardiac testing. Back to top Article Information Corresponding Author: Ron Blankstein, MD, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115 (rblankstein@partners.org). Conflict of Interest Disclosures: None reported. References 1. Schmidt T, Maag R, Foy AJ. Overdiagnosis of coronary artery disease detected by coronary computed tomography angiography: a teachable moment. JAMA Intern Med. 2016;176(12):1747-1748.PubMedGoogle ScholarCrossref 2. Hulten E, Bittencourt MS, Singh A, et al. Coronary artery disease detected by coronary computed tomographic angiography is associated with intensification of preventive medical therapy and lower low-density lipoprotein cholesterol. Circ Cardiovasc Imaging. 2014;7(4):629-638.PubMedGoogle ScholarCrossref 3. Cury RC, Abbara S, Achenbach S, et al; Endorsed by the American College of Cardiology. CAD-RADS(TM) coronary artery disease—reporting and data system: an expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr. 2016;10(4):269-281.PubMedGoogle ScholarCrossref 4. Ladapo JA, Hoffmann U, Lee KL, et al. Changes in medical therapy and lifestyle after anatomical or functional testing for coronary artery disease. J Am Heart Assoc. 2016;5(10):e003807.PubMedGoogle ScholarCrossref 5. Bittencourt MS, Hulten EA, Murthy VL, et al. Clinical outcomes after evaluation of stable chest pain by coronary computed tomographic angiography versus usual care: a meta-analysis. Circ Cardiovasc Imaging. 2016;9(4):e004419.PubMedGoogle ScholarCrossref

Journal

JAMA Internal Medicine – American Medical Association

Published: May 1, 2017

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