CardioExchange Archive

The American College of Cardiology (ACC) and other medical societies have released lists of commonly overused or misused tests and procedures. The action is part of Choosing Wisely, a broad initiative from the ABIM foundation.

Here are the five tests or procedures identified by the ACC:

1. Cardiac imaging tests (particularly, stress tests or advanced noninvasive imaging) should not be given if there are no symptoms of heart disease or if high-risk factors like diabetes or peripheral arterial disease are not present.
2. Cardiac imaging tests (particularly, stress tests or advanced noninvasive imaging) should not be given as part of a routine annual follow-up in patients who have had no change in signs or symptoms.
3. Cardiac imaging tests (particularly, stress tests or advanced noninvasive imaging) should not be given before performing low-risk surgery that is not related to heart disease.
4. Echocardiography should not be used as routine follow-up care in adults with mild heart valve disease who have had no change in signs or symptoms.
5. Patients experiencing a heart attack and undergoing PCI should not have stents placed in an artery or arteries beyond those responsible for the heart attack.

Here is the list from the American Society of Nuclear Cardiology:

1. Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.
2. Don’t perform cardiac imaging for patients who are at low risk.
3. Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.
4. Don’t perform cardiac imaging as a preoperative assessment in patients scheduled to undergo low- or intermediate-risk noncardiac surgery.
5. Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.

Here are some other cardiovascular-related items from other medical societies:

• American College of Physicians: Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.
• American College of Physicians: In patients with low pretest probability of venous thromboembolism, obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
• American College of Radiology: Don’t image for suspected pulmonary embolism without moderate or high pre-test probability.
• American Academy of Family Physicians: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.

To read two recent posts on the Choosing Wisely campaign by Harlan Krumholz, in which he called for – and received – members’ ideas on ways to cut spending in cardiology, see here and here.