Routine coronary angiography for effort angina

The low risk cardiac patient: an opportunity for cost containment

The pressure to maintain high standards in the face of diminished medical funding has promoted a search for a low risk group of patients seen in cardiac practice in whom diagnostic and therapeutic technologies can be kept to a minimum. This study reports experience in a single cardiology practice in which all patients had a history taken, a clinical examination performed, and most had an electrocardiogram. Thereafter investigation and treatment was tailored to the individual patient's need. A retrospective study of 113 patients revealed that 93 (82%) had high risk characteristics prior to their death: cardiac failure; unstable coronary heart disease; clinical or laboratory evidence of poor systolic function of the left ventricle or inoperable coronary artery disease; elective major surgery; evidence of poor prognosis due to non-cardiac disease. In contrast, only 124 (21%) of 588 consecutive patients seen in consultation had high risk characteristics. The prevalence adjusted mortality ratio of high to low risk cases was 17.4/1 and in one third of cases, high risk status was less than 6 months duration. In a prospective study, 144 cases were classified at high risk and 373 at low risk. Three year survival rates were 74 and 91% respectively (p < 0.0001). 46 (12.3%) of the 373 patients initially at low risk subsequently developed clinical features which permanently placed them in the high risk category. The 3 year survival in the low to high risk converters was 47% compared with 97% survival in those remaining at low risk throughout the period of observation (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise testing? Not at all

The traditional approach to the ambulatory patient with suspected or definite coronary disease is to evaluate the clinical features, to perform non-invasive tests for myocardial ischaemia, and to proceed, if necessary, to coronary angiography and coronary revascularisation. However, when the results of the exercise tests are discordant with the clinical classifications they are usually misleading as diagnostic tools. When the exercise test is used to assist prognostication, the information provided overlaps with that available to the clinician and only the presence of ST segment depression is an independent prognosticator. The amount of ST segment shift has been found to be an inferior prognosticator to the severity of disease seen on a coronary angiogram and the latter allows for appropriate decisions to be made regarding coronary angioplasty or bypass surgery. A more appropriate use of exercise testing is as a gate for coronary angiography if there is real doubt or the nature of the chest pain or as an aid in therapeutic decisions if the coronary angiography interpretation is difficult.