ISCHEMIA Study: Changing the Ethical Standard of Discussing Heart Care With Patients

The “New” Clinic Visit

“Have a seat Mrs. Jones. You too Mr. Jones. Mrs. Jones, as you know, your internist Dr. Smith was concerned about your complaints of shortness of breath and tightness walking up hills and ordered a stress test. He asked you to come to my cardiology office today to discuss the results. You exercised well but the pictures made of your heart show a fairly large area of the muscle apparently not receiving adequate blood flow. The strong suspicion is that you have blocked heart arteries, one or more, which is not impossible with your history of taking blood pressure and cholesterol medications. We have several approaches from here we can choose. In the past, we would schedule a procedure called a heart catheterization, threading a tube through your wrist or leg artery, and inject dye to image any blocked areas. If appropriate, we would place one or more stents at that same time unless the disease was so bad you needed to consider a bypass operation. Now we know that for most people like you, this has no better a chance of keeping you alive and well compared to adding aspirin and a medication called a beta-blocker. We would schedule an outpatient test called a CT angiogram to insure you did not have the most serious of blockages, a severe left main narrowing, and if you do not, we can proceed with the medications, education on diet, and referral to a cardiac rehabilitation exercise program. It is likely if you make significant changes to your diet and habits, you will not need any more procedures. If you worsen, then we can always do the catheterization and stents. Do you understanding the options you have?”

Why the Change? The ISCHEMIA Study

This week one of the most anticipated and expensive trials in the history of cardiology care ($100 million) was presented at the annual American Heart Association meeting in Philadelphia, The ISCHEMIA study. This study randomized just over 5,000 patients identified at a network of international treatment centers with moderate to large zones of ischemia on stress testing in the setting of suspected CAD. Many had a coronary CT angiogram to evaluate for and exclude severe disease of the left main trunk and those without it were randomized to…