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Improved patient selection and practice patterns may lower number of negative tests for CAD

November 09, 2017

Hospitals with lower rates of finding CAD by catheterization were more likely to perform the procedures on younger patients, women, those with a lower likelihood of disease (as indicated by a low Framingham or Diamond and Forrester risk score), who presented with atypical symptoms and who had negative non-invasive diagnostic testing done prior to angiography. Not surprisingly, patients at higher risk of being diagnosed with obstructive coronary artery disease were more likely to have hypertension, diabetes and other expected risk factors. In general, the size and type of hospital (e.g., teaching hospital, public vs. private) and setting did not change the findings.

Researchers identified 565,504 patients without known heart disease who underwent elective cardiac catheterization at 691 hospitals nationwide over a three-year-period to evaluate the rate of finding obstructive CAD. Authors defined CAD as any major epicardial vessel stenosis at 50 percent or higher, but similar patterns remained even when alternate definitions were applied.

"The decision to perform catheterization should be selective and ideally limited to patients with moderate to high pre-test probability for CAD," said Dr. Douglas, who also cautions that there are other, valid reasons to do a catheterization besides the expectation of finding obstructive CAD, such as patient reassurance.

To provide additional guidance to cardiologists, ACC is currently working on appropriate use criteria for ordering invasive diagnostic coronary angiographies with release expected this winter. In the meantime, Dr. Douglas advocates for closer consideration of those clinical factors known to be most strongly associated with CAD, including advancing age, risk factors and typical symptoms. A careful assessment of patients' risk and presenting symptoms, as well as results of any stress and other non-invasive tests should be considered.

Source: American College of Cardiology