Five things physicians and patients should question in Cardiology: ACC recommendations

USA: The American College of Cardiology, as part of the Choosing Wisely campaign, has released a new list of “Five Things Physicians and Patients Should Question” in cardiology. The recommendations are based on published national guidelines and aim to broadly represent the field of cardiology.

The new Choosing Wisely campaign encourages conversations between clinicians and patients about potentially unnecessary tests, treatments, and procedures. The list includes recommendations to:

1. Avoid the routine use of invasive hemodynamic monitoring with pulmonary artery catheters in patients with uncomplicated acute decompensated heart failure -- Weighing risks and benefits, the 2021 Expert Consensus update and the 2022 Guideline concluded that routine use of invasive hemodynamic monitoring with pulmonary artery catheters is not recommended.

2. Avoid performing atrial fibrillation ablation for discontinuing chronic anticoagulation -- Discontinuation of anticoagulation should not be the sole motivating factor for undertaking AF ablation. Informed consent and shared decision-making should include a discussion of the indication to continue anticoagulation as indicated by standard stroke risk scores and clinical practice guidelines.

3. Avoid routine imaging stress tests or coronary CT angiography for the workup of palpitations or presyncope -- Palpitations, dizziness, lightheadedness, and presyncope are common symptoms. These are not infrequently worked with various testing modalities, including advanced cardiac imaging (PET or SPECT myocardial perfusion imaging, cardiac magnetic resonance imaging, or cardiac computed tomography). Without other symptoms or signs of cardiovascular disease, cardiac imaging beyond a transthoracic echocardiogram is rarely warranted.

4. Avoid obtaining a coronary artery calcium score in patients with known clinical atherosclerotic cardiovascular disease -- A coronary artery calcium (CAC) test is useful to assess risk and aid treatment decisions in many individuals without an established diagnosis of coronary artery disease. It does not contribute information for the risk assessment or treatment when a clinical atherosclerotic cardiovascular disease (ASCVD) diagnosis has been established. 

5. Avoid obtaining routine serial echocardiograms for chronic heart failure if there has been no change in signs, symptoms, or management -- For patients who are stable clinically and in whom no recent change in management has occurred or is contemplated, a routine schedule of serial echocardiograms is not useful.

According to Keating, ACC’s Choosing Wisely Work Group sought broad input during the drafting process, including from ACC’s Board of Governors and Science and Quality Committee. The mission of Choosing Wisely, she notes, is to advance dialogue that helps patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary. The new ACC list, along with those of more than 75 other societies, can be found on ChoosingWisely.org.