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.
“Both cardiologists and primary care physicians [PCPs] have trouble balancing these psychological and emotional factors with scientific evidence in decision making, and this leads to them 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. And once there, if any lesions are identified, “the die is cast” for percutaneous coronary intervention (PCI), she said.
Dr. Lin, of the University of California, San Francisco, 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 them 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, Dr. Lin drew one-third from San Francisco, one-third from the city's suburbs, and one-third from a rural county. The PCPs and cardiologists were interviewed separately to encourage frank discussion.
The 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.
One of the cases was that of a 45-year-old man with a family history of myocardial infarction. He worked out three times a week and was asymptomatic. However, his wife 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 ended up recommending PCI for all three of the case-study patients, even though they acknowledged that no clinical evidence suggested the procedure would be more beneficial than medical therapy.
Several major themes emerged from the physician discussions: They felt guilt over the possibility of missing a lethal lesion, patient expectation of testing and intervention, and liability fears.
The fear of guilt was a particularly strong motivator for more tests and interventions. One PCP summed this when he said: “I had a healthy 42-year-old who dropped dead while jogging. I'm always afraid of missing that widow-maker lesion.”
A cardiologist echoed that view: “I don't think you can ignore a lesion, because then, if something happens, it's your fault.”
“I think it demonstrates the tendency of physicians to look for solutions based on action,” said Dr. Lin.
In addition, the participants stuck to their recommendations despite their intellectual understanding of the clinical evidence. “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,” said one cardiologist. “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 PCPs and cardiologists said their patients expected testing regardless of what [the caregivers] thought of it.”
Concerns about medicolegal liability also strongly influenced the decision making. “We all would feel more comfortable treating more patients medically if we weren't afraid of being sued,” said one PCP.
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.”
All of these factors “culminate in a cascade effect where screening leads to more testing and eventually to the cath lab,” she said.
As the study shows, physicians tend to look for action-based solutions, Dr. Grace Lin said. Michele G. Sullivan/Elsevier Global Medical News