Last week, the Society for Cardiovascular Angiography and Interventions (SCAI) published a list of five test and procedures to be avoided. The list is part of a comprehensive effort that spans across all areas of health care to encourage conversation and shared decision making by patients and their healthcare providers. SCAI’s list was developed as part of Choosing Wisely®, an initiative of the ABIM Foundation, which now features dozens of lists – more than 250 recommendations of procedures to avoid in certain circumstances – that were developed by the experts in each field.
Since SCAI is medical society composed of interventional cardiologists – heart doctors who diagnose and treat problems with the heart and blood vessels with minimally invasive procedures – SCAI’s list focuses on heart tests and treatments that warrant extra consideration. While we all should always discuss every procedure with our doctors, these five deserve extra conversation.
SCAI’s five recommendations are as follows, along with a few comments on why you don’t need each test or procedure routinely and when you might need it.
1. Avoid routine stress testing after angioplasty, which often uses stents, to open blocked heart arteries.
Why you DON’T need it routinely: If you are free of chest pain and shortness of breath after heart procedures, you probably don’t need regular stress tests. If you are feeling well without shortness of breath or chest pain, it usually means your heart arteries are in good shape, with no need for further procedures. Stress tests sometimes mistakenly produce abnormal results even when nothing is wrong, and false results can lead to anxiety, further testing, and additional risk of complications.
When you DO need it: Formal guidelines from cardiology societies indicate that stress testing is reasonable after two years have passed since your heart procedure. Stress testing after coronary artery procedures may be particularly appropriate in a variety of situations. Examples include:
- if new chest discomfort or shortness of breath occurs
- if your blockages did not cause symptoms before the first heart artery procedure
- if the blockage that was fixed was in a particularly dangerous position in the heart
- if there are remaining blockages in your heart that were not fixed
- if you are planning a new exercise program or extreme physical activity
2. Avoid having an angiogram after procedures to unblock your heart arteries if you are free of symptoms, or if you have stable heart symptoms and the stress test shows nothing more than mild abnormalities.
Why you DON’T need it routinely: If the angioplasty procedure to unblock your heart arteries fixed all of the significant blockages, usually they don’t grow back. If they don’t grow back and new blockages don’t develop, then another angiogram of your heart will not be of any benefit. (And heart tests always carry some risks.) So if your symptoms go away entirely after the procedure, or you have stable mild symptoms and nothing bad shows up on a stress test, then you probably don’t need another angiogram.
When you DO need it: Heart angiograms may be necessary if a stress test shows major problems or if you are having lots of chest pain and hope to get it fixed. If you develop chest pain that occurs when you are resting or worsens from one day to the next, call your doctor immediately or go to the nearest emergency department. In that case, an angiogram may be necessary.
3. Avoid having an angiogram to assess your risk of heart attack or death if you are too ill or unwilling to undergo additional procedures to reduce that risk. These additional procedures might include heart bypass surgery or heart stenting.
Why you DON’T need it routinely: This mostly applies to persons who know they have heart artery blockages. If you are considering an angiogram to find out if you are likely to die of heart disease, then you are probably willing to do something about it. Otherwise there is no point to doing the procedure
When you DO need it: Having an angiogram to assess your risk of heart attack or death might be beneficial to determine if other procedures can be undertaken safely. In such cases, you might not be willing to undergo further heart procedures to fix blockages, but you might consider undergoing other kinds of procedures if the risk is not too high.
4. Avoid having an angiogram of your heart to assess risk if you don’t have symptoms of heart blockage and you have done a full stress test that shows no problems.
Why you DON’T need it routinely: If you don’t have heart symptoms and your stress test is normal (assuming you exercised to a good heart rate), your doctor already knows that your risk of heart troubles is very low. In that case, having an angiogram of your heart would not give your doctor any additional useful information about your risk of heart disease.
When you DO need it: We couldn’t think of a reason why you would need an angiogram in this situation.
5. Avoid heart artery stenting if you don’t have heart symptoms and your heart is getting enough blood according to stress tests or pressure measurements inside your heart arteries.
Why you DON’T need it routinely: Heart artery blockages that are not causing symptoms or are not limiting blood flow to the heart are best treated with medications. Fixing them with heart artery stents does not prevent death or heart attacks. And if you are not having any symptoms, it can’t make you feel any better.
When you DO need it: Rarely, tests that measure blood flow to the heart can fail to show blockages that really do exist. If there is such a blockage in a critical part of the heart, even a person without any symptoms might benefit from fixing the blockage.
Questions to Ask Your Doctor About Cardiovascular Tests and Procedures
The questions below can help you start a conversation with your physician/practitioner about recommended cardiovascular tests.
Questions About Tests You are Considering
- What information will this test give us about my cardiovascular disease?
- What are the benefits of this test?
- Does this test carry any risks? If so, what are the risks?
- How accurate is this test?
- What are some likely next steps if the test indicates a problem?
Questions About Procedures You Are Considering
- Will this procedure prolong my life or improve my quality of life?
- What are the benefits of this procedure?
- Are there other procedures I should consider in addition to this one?
- Does this procedure carry any risks? If so, what are the risks?
- How successful is this procedure?
- What are some likely next steps after this procedure?
What Should I Do If I Have Other Questions?
Ask them. Contact your healthcare provider and ask all of your questions. Any time you have health questions, the conversations you have with your doctor are the key to successful results. Ask every question you have.
We hope you will use SecondsCount.org to learn more about your cardiovascular health and treatment options. SecondsCount.org was developed by the Society for Cardiovascular Angiography and Interventions.