Noninvasive Diagnosis and Prognosis Assessment in Chronic Coronary Artery DiseaseResponse to Gibbons
Stress Testing With and Without Imaging Perspective
Over the past 30 years, there have been great advances in cardiovascular imaging and treatment. Early in this period, new techniques were usually investigated on a limited research basis before widespread adoption. This research helped to develop evidence to define proper application in clinical practice. Sometimes, this evidence did not support the initial promising reports. Pulmonary blood volume measurements, regional ejection fraction images, digital subtraction angiography, stress echocardiography using transesophageal pacing, pacemaker therapy for hypertrophic cardiomyopathy, laser coronary angiography, and aortic valvuloplasty were all appropriately tested on a limited scale and abandoned.
Response by Min and Shaw see p 257
In the past 15 years, declining Medicare reimbursements have contributed to a “make it up on volume/grow the business” mentality in medicine that often embraces a broader application of new technology before it has been adequately studied to establish its correct role. Many observers have commented that clinical practice often now “runs ahead of” guidelines. Should this pattern continue with respect to newer technology, eg, computed tomographic (CT) angiography, for the diagnostic and prognostic assessment of chronic coronary artery disease (CAD)? To answer this question, the reader must understand the current health-care crisis, the overwhelming evidence supporting the current use of stress imaging with or without imaging, and the limited evidence for CT angiography.
The Current Health-Care Crisis
The need for fundamental health-care reform is increasingly recognized. For the past 2 years, all the major presidential candidates have defined positions on health-care reform. A prominent 2-page advertisement in the Sunday New York Times signed by 10 past political leaders, including a former chairman of the Federal Reserve Board, summarized it well:
“Mounting healthcare costs…threaten American competitiveness, and, if they remain unchecked, could even bankrupt the country. …The prognosis for our nation’s health is beyond unacceptable—it is inconsistent with America’s long-standing tradition of stewardship.”1 …