The Disconnect Between Practice Guidelines and Clinical Practice—Stressed Out
- George A. Diamond, MD;
- Sanjay Kaul, MD
- Author Affiliations: Division of Cardiology, Cedars-Sinai Medical Center, and the David Geffen School of Medicine, University of California, Los Angeles.
Since this article does not have an abstract, we have provided the first 150 words of the full text.
- KEYWORDS:
- CORONARY INTERVENTION, PERCUTANEOUS
- CORONARY ARTERY DISEASE
- EVIDENCE-BASED MEDICINE
- MEDICARE
- MYOCARDIAL ISCHEMIA
- PHYSICIAN'S PRACTICE PATTERNS
- PRACTICE GUIDELINES AS TOPIC
- REIMBURSEMENT MECHANISMS
Despite increasing evidence supporting plaque instability as the proximate cause of atherosclerotic events,1,2 treatment strategies continue to focus on the anatomic stenosis.3 This preoccupation with coronary luminology causes clinicians to perform stress tests and angiograms to identify flow-limiting lesions, even among asymptomatic patients, and to mitigate the effects of these lesions by direct mechanical or surgical intervention. As a result, clinical practice guidelines currently recommend revascularization when stress testing reveals demonstrable myocardial ischemia despite optimal medical management.3,4
Unfortunately, the guidelines are not as clear as they might be on this matter. For example, one guideline reads as follows3:
[Percutaneous coronary intervention] may be considered in patients with [Canadian Cardiovascular Society] class III angina and no evidence of ischemia on noninvasive testing or who are undergoing medical therapy and have 2- or 3-vessel [coronary artery disease] with significant proximal [left anterior descending …
