Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, February 10, 2009

Cardiac Question

I have a question for all my esteemed cardiology colleagues out there; preferably the ones following evidence-based guidelines instead of the ones who order tests based on their student loan, tuition, house and car payment due dates.

Now that it's been shown that stenting coronary arteries only helps in the setting of acute coronary syndrome or unstable angina (ie, actual symptoms) what is the purpose of "routine" annual stress testing for patients with stable coronary disease?

Assuming that all of them are on statins with an LDL goal of 80 or less, have been convinced to stop smoking and have their blood pressures adequately and have normal LV function by echocardiogram, why do they need repeat stress testing in the absence of symptoms? For that matter, without a murmur or symptoms suggestive of valvular heart disease and a structurally normal heart documented once (you can't call yourself a cardiac patient without having an ehco) what advantage is there from repeating echocardiograms on a regular basis either?

Seems to me like the main thing outpatient cardiologists do -- other than ordering annual stress tests and echoes, along with EKGs at every visit -- is exhort patients to exercise and stop smoking. What really roasts my beef is when patients ignore the same advice from me.


At Wed Feb 11, 01:16:00 AM, Anonymous Anonymous said...

There is a difference between a doctor ,you have been seeing every few months for the past 10 years, telling you, you should stop smoking and drop a few pounds. Vs. Hearing the same information from the guy you see maybe twice a year for the last 3 years watching you sweat your balls off and struggle on a treadmill.

I believe good cardiologist not only mention the need to stop smoking or the need to change diet, they point the patient back to their GP for follow up on how to do those things.

At Wed Feb 11, 01:31:00 AM, Blogger janemariemd said...

Well, to fatten the cardiologist's wallet of course! Last time I looked at the literature, there was no benefit to patients getting annual stress tests as long as they were doing OK.

Don't underestimate the impact of YOUR nagging of your smokers about their bad habit--perhaps the cardiologist's words are just the last straw, tipping them from "pre-contemplaters" to actual quitters.

At Wed Feb 11, 08:30:00 PM, Anonymous Anonymous said...

I am an FP like you and have similar skepticism, but I am also a physician who lost a malpractice case regarding a CP pt. with completely normal and by the guidelines work-up who then died 3 months later of an MI. So CYA plays some role as merely doing what is right according to the 'experts' is insufficient sometimes.

At Fri Feb 20, 12:30:00 AM, Anonymous Anonymous said...

In the absence of symptoms or clincal change of some type, there really is no need for routine annual stress testing (remember Tim Russert? - he still died despite a recent negative stress test). However, the AHA/ACC/ASNC guidelines for nuclear stress testing still indicate that testing post PCI or post CABG are acceptable indications, so the tests still get ordered and done.... all about the bottom line.


At Wed Jan 27, 06:10:00 AM, Anonymous Anonymous said...

13 minutes of Bruce protocol stress test will fatten up the cardiologists wallet because that much exertion enlarges every heart. That is why Tim Russert and thousands of Americans every year die during and shortly after taking the test. To have a nurse or medical assistant stand by and watch as the patient destroys there own heart. its sad. Bruce protocol stress test. Want to enlarge your right ventricle? Want to speed your way to pulmonary hypertension and a slow miserable death? Take a bruce test. enlarge left atrium? Bruce test. Cardiologists you should be ashamed.


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