All of these factors “culminate in a cascade effect where screening leads to more testing and eventually to the cath lab,” she said, citing a PCP who referred to the hypothetical patient's elevated calcium load. “This guy's wife has bought him much more than a scan—she has bought him an entrée to the whole garden path of testing. Any equivocal test and he's ending up in the cath lab.”
“This demonstrates that once a patient has any positive screen, it's very difficult to prevent a referral to a cardiologist and eventually, to the cath lab,” Dr. Lin said. “Once he reaches there, the cardiologists told us that if any amenable lesion is found, that person is almost certain to get a PCI.”
The culture of the catheterization lab also plays into this inevitable progression. A cardiologist explained, “By this time the die is cast. In our practice, where we don't get paid per procedure, we would have difficulty getting out of the lab because the cath lab staff wouldn't let us out unless we did something with that lesion.”
The cascade of emotion and worry is what appears to drive the patient with stable CAD to a PCI, Dr. Lin said. Even balancing the possible complications of the procedure with the evidence that it probably yields no additional benefit wasn't enough to sway physicians to medical therapy alone.
“One cardiologist put it like this,” she said. “'If you do the procedure and there's a complication, that's a complication. But if you don't do it and there's an event—that's a mistake.'”
The study “demonstrates the tendency of physicians to look for solutions based on action,” said Dr. Grace Lin. Michele G. Sullivan/Elsevier Global Medical News