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Study: Add-On Heart Imaging Grossly Overused

April 10, 2012
Written by: , Filed in: Cardiac Imaging
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“While we’ve got the catheter in there, we might as well do a left ventriculography”—whether or not it’s needed. That seems to be standard procedure during a coronary angiogram, according to a study published online March 30 in the American Heart Journal.

The procedure is added even when the patient has recently undergone a better and less-invasive test that provided the same information, the study found.

The study’s first author, Ronald Witteles, MD, called the rate of unnecessary tests “shockingly high.” He added:

If a patient recently had an echocardiogram or a nuclear study, it didn’t make them less likely to have the left ventriculography procedure—it made them more likely. That is impossible to explain from a medical justification standpoint.

Dr. Witteles is assistant professor of cardiovascular medicine and program director of Stanford University‘s internal medicine residency training program. He was quoted in a Stanford news release via EurekAlert!

Left ventriculography, a 50-year-old test, assesses heart function by measuring  the “ejection fraction”—the percentage of blood ejected with each heartbeat. Following a coronary angiogram, after the catheter is threaded through the blood vessels to the heart, contrast dye is inserted, and X-rays are taken, it’s easy to add a left ventriculography. In fact, the study found it happened in 81.8 percent of cases.

It involves moving the catheter across the aortic valve, inserting another dose of contrast dye, and exposing more X-rays. Takes an extra five minutes, costs another $300, and, hey, why not check while everything is set up, right?

The problem is that sticking a catheter into the heart can, in rare cases, dislodge a blood clot and cause a stroke. The test also increases the risk of heart arrhythmia, increases radiation exposure, and increases the risk of side effects from the contrast dye.

If there were a medical reason for adding the test, fine. But the study looked at patients who, within 30 days and without an intervening diagnosis of a new problem, had undergone another imaging study (echocardiogram or nuclear cardiac imaging). Those tests provide the same information less invasively and, often, with better-quality images. Adding left ventriculography would be duplicative.

For those patients, the left ventriculography rate was a stunning 88 percent. “The only logical conclusion,” Dr. Witteles said, “is that a practice pattern is being defined in which tests beget more tests, whether they’re necessary or not.”

The study concludes, less heatedly, “New clinical practice guidelines should be considered to decrease the overuse of this invasive test.”

Related seminar: Cardiac Imaging


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