WASHINGTON — When it comes to recommending angioplasty for stable coronary artery disease, evidence can take a backseat to worry, guilt, and the fear of legal liability.
“It appears that both cardiologists and primary care physicians [PCPs] have trouble balancing these psychological and emotional factors with scientific evidence in decision making, and this leads them to recommending more tests and procedures,” which eventually culminate in a trip to the cardiac catheterization lab, Dr. Grace Lin said at a conference sponsored by the American Heart Association. Once there, if any lesions at all are identified, “the die is cast” for percutaneous coronary intervention (PCI), she said.
Dr. Lin drew these conclusions from a series of six focus-group meetings she held with 28 primary care providers and 20 cardiologists (13 interventional and 7 noninterventional). She presented each group with three case scenarios based on actual patients with symptoms of stable coronary artery disease (CAD), and asked the participants to describe how they would arrive at a treatment recommendation.
All of the physicians lived in California; their mean duration of practice was 17 years. To help identify any regional differences, she drew one-third from San Francisco, one-third from the city's suburbs, and one-third from a rural county.
“We also interviewed PCPs and cardiologists separately, to encourage frank discussion,” said Dr. Lin of the University of California, San Francisco.
Group discussions were set around three case scenarios representing minimally symptomatic or asymptomatic patients for whom the current evidence shows no benefit of PCI over optimal medical therapy. She described one of the cases: a 45-year-old male with a family history of myocardial infarction. The patient worked out three times each week and was asymptomatic. His wife, however, was worried about his family history and bought him a coronary calcium scan for his birthday. The scan showed a calcium score of 745.
His stress test showed ST-segment depressions of 1–2 mm. A catheterization revealed a tight lesion in the left anterior descending artery.
Dr. Lin asked the group to discuss a range of recommendations, from reassurance and risk reduction interventions to medical therapy, PCI, and coronary artery bypass grafting.
All of the physicians in each group ended up recommending PCI for all three of the hypothetical patients, Dr. Lin said—despite their acknowledgement that no clinical evidence supported the procedure as more beneficial than medical therapy in either the short or long term.
Several major themes emerged from the physician discussions: guilt over the possibility of missing a potentially lethal lesion, patient expectation of testing and intervention, and liability fears.
The fear of guilt arising from a missed lesion was a particularly strong motivator for more tests and interventions. One primary care physician spoke quite eloquently of this, said Dr. Lin. “I had a healthy 42-year-old who dropped dead while jogging. I'm always afraid of missing that widow-maker lesion.”
A cardiologist expressed a similar view. Despite the data suggesting that PCI is no better than medical therapy for these patients, “I don't think you can ignore a lesion, because then, if something happens, it's your fault.”
“This belief was shared by most of the physicians in our groups,” Dr. Lin said. “I think it demonstrates the tendency of physicians to look for solutions based on action.”
Interestingly, the participants stuck to their recommendations despite their intellectual understanding of the clinical evidence. According to one cardiologist, “I think we know we are not necessarily preventing heart attacks by treating asymptomatic stenosis with PCI. We are going to prevent future heart attacks with lipid-lowering drugs, aspirin, and ACE inhibitors. But nonetheless, when that patient leaves with an open artery—that is the best that my interventional partners can deliver.”
Physicians aren't alone in wanting some concrete action in these cases, Dr Lin said. “Patient expectations are a frequent reason for testing. Both our PCPs and cardiologists said their patients expected testing regardless of what they themselves thought of it.”
One cardiologist put it this way: “If the patient is worried enough to come in and see me, we need to do this testing to reassure him.”
Concerns about medicolegal liability also strongly influenced the decision making. A PCP noted, “We all would feel more comfortable treating more patients medically if we weren't afraid of being sued. With a jury of laypeople, it's hard to justify not stenting despite the evidence, and because of that it's hard to just treat medically and not be afraid of a lawsuit.”
Again, Dr Lin observed, physicians felt very strongly about this despite evidence to the contrary. “There are no data linking additional testing with fewer lawsuits.”