SCAI's Five Recommendations for Choosing Tests

The Society for Cardiovascular Angiography & Interventions (SCAI) has published a list of five tests and procedures to be avoided. The list is part of a comprehensive effort that spans all areas of healthcare 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 American Board of Internal Medicine (ABIM) Foundation, which now features dozens of lists—more than 250 recommended procedures to avoid in certain circumstances—that were developed by the experts in each field.

Since SCAI is a 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 should always discuss every procedure with our doctors, these five deserve an extra conversation.

SCAI’s five recommendations are as follows, along with an explanation of why you don’t need each test or procedure routinely and when you might need it.

1. Avoid routine stress testing after heart procedures

Why you DON’T need it routinely: If you’re free of chest pain (angina) and shortness of breath after heart procedures that unblock your heart arteries (angioplasty), you probably don’t need regular stress tests. If you’re 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 the additional risk of complications.

When you DO need it: Formal guidelines from cardiology societies indicate that stress testing is reasonable after two years since your heart procedure. Stress testing after coronary artery procedures may be particularly appropriate in a variety of situations, including the following:

  • If new chest discomfort or shortness of breath occurs
  • If your blockages didn’t cause symptoms before the first heart artery procedure
  • If the fixed blockage was in a perilous position in the heart
  • If there are remaining blockages in your heart that weren’t fixed
  • If you’re planning a new exercise program or extreme physical activity

2. Avoid getting an angiogram after angioplasty if you’re free of symptoms or have stable heart symptoms

Why you DON’T need it routinely: If the procedure to unblock your heart arteries (angioplasty) fixed all of the significant blockages, there is no need to have another angiogram, X-ray imaging to see your heart's blood vessels. Heart tests carry some risks. So, if your symptoms go away entirely after the procedure or you have stable mild symptoms, 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 you have chest pain and hope to fix it. If you develop chest pain when resting or it 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 a heart attack or death if you’re too ill or unwilling to undergo additional procedures

Why you DON’T need it routinely: This mainly applies to individuals who know they have heart artery blockages. If you’re considering an angiogram to find out if you’re likely to die of heart disease, then you’re probably willing to do something about it. Otherwise, there’s no point in doing the procedure.

When you DO need it: Having an angiogram to assess your risk of a 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 procedures if the risk isn’t too high.

4. Avoid having an angiogram of your heart if you don’t have symptoms of heart blockage and you’ve had a 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 your risk of heart troubles is very low. In that case, having an angiogram of your heart wouldn’t give your doctor any additional useful information about your risk of heart disease.

When you DO need it: We couldn’t think why you would need an angiogram.

5. Avoid heart procedures if you don’t have symptoms and stress tests or pressure measurements show your heart gets enough blood

Why you DON’T need it routinely: Heart artery blockages that aren’t causing symptoms or aren’t limiting blood flow to the heart are best treated with medications. Fixing them with heart artery procedures doesn’t prevent death or heart attacks. It can't make you feel better if you don’t have any symptoms.

When you DO need it: Rarely, tests that measure blood flow to the heart can fail to show blockages that do exist. If there’s such a blockage in a critical part of the heart, even a person without any symptoms might benefit from fixing the blockage.

If you have other questions about certain tests and procedures

Ask your doctor if you’re still unsure about a certain test or procedure. Any time you have health questions, conversations with your doctor are the key to successful results. A good starting point is to review these questions to ask about cardiovascular tests and procedures.