Coronary angioplasty practice in the United States.

Coronary Angioplasty Practice in the United States We wish to express some concern about the article by Dr Eric J. Topol and colleagues1 analyzing coronary angioplasty practice in the United States based on insurance-claims data. The key conclusion of this study was that the majority of coronary angioplasty procedures performed in this country are not preceded by objective evidence of myocardial ischemia, with the obvious conclusion that many of these procedures are being performed unnecessarily. Although the intent may have been to study patients with mainly stable angina pectoris, we strongly suspect that many of these patients were, indeed, unstable clinically. Table 1 of this article states that the median length of stay for patients without prior exercise testing was 6 days, which is roughly twice the average length of stay for patients with stable coronary disease undergoing elective percutaneous transluminal coronary angioplasty. Of these patients, 67% to 68% were labeled with a diagnosis of "angina"; however, in the absence of a large number of periprocedural complications, it is hard to imagine a median length of stay of 6 days for the "stable" anginal patient. The median length of stay was only 3 days for those with prior exercise testing, and this is probably a greater reflection of those patients with a truly stable coronary artery disease. Thus, we would like to suggest that many of the patients without prior exercise stress testing were relatively unstable and were not deemed appropriate candidates for such. There are many other potential reasons for not performing stress testing before coronary angioplasty, and indeed, there are a number of class I indications, based on the American College of Cardiology/American Heart Association guidelines,2 for the justifiable use of coronary angioplasty in patients without prior exercise stress testing, including those with angina pectoris who have proved unresponsive to medical therapy or intolerant of medical therapy. Although we have no doubt that some interventional cardiologists in the United States are overusing coronary angioplasty for financial rewards, we feel that the majority of interventional cardiologists do follow published practiced guidelines to the benefit of our patients. Data as constructed in the article of Topol et a1l should not be used by governmental agencies and third party insurers as a definitive assessment of utilization review.