The Call for a New Paradigm in Evaluating Suspected Coronary Artery Disease
The current diagnostic pathway for evaluating chest pain patients with suspected coronary artery disease (CAD) is fraught with numerous challenges, including ambiguity in clinical decision-making, an over-reliance on various testing modalities and, for many patients, needless expense. It is estimated that over $6.7 billion is spent annually in the US on noninvasive and invasive approaches for the workup of these patients.1
In many instances, the concern of avoiding a misdiagnosis that would lead to a cardiac event has created a management culture of “defensive medicine” and a reflex referral to cardiologists which, in turn, frequently results in abundant diagnostic testing of these patients and, in some cases, unnecessary cardiac procedures. Also, these noninvasive diagnostic tests may trigger the performance of therapeutic procedures such as angioplasty and stenting that, in a low-risk patient, may tilt the ratio of benefit and risk toward the latter. In the aggregate, the unfettered use of such diagnostic tests and the downstream procedures can be risky and costly to both patients and the healthcare system.
We need to redirect the initial evaluation of low- to intermediate-risk patients presenting with symptoms suggestive of CAD back to the primary care and internal medicine setting to enable these physicians to play a more prominent role in the initial evaluation and decision-making process.
The Value to the System and Patients Alike
The diagnosis and management of suspected CAD is extremely resource- and labor-intensive and creates a burden on emergency departments and challenges for outpatient practices. In the US alone, the evaluation of suspected CAD is associated with millions of stress tests and angiograms yearly. Importantly, of the patients presenting with symptoms, approximately 90% of those evaluated by primary care physicians (PCPs) are ultimately diagnosed with non-cardiac issues.2
The benefit of shifting physician decision-making, from routine cardiology specialty referral to the primary care physician and practicing internist, is that we can better risk-stratify patients with a lower risk profile and avoid unnecessary referral and procedures that have not been shown to be of any clinical benefit. This would result in better care and help alleviate the burden on the financial health of the managed care system while providing patients with a more selective and tailored approach to management and less expensive treatment.