Coronary computed tomographic angiography and a shout-out to SMART EM

I’m tremendously enjoying the SMART EM podcasts, about which I may write more in the future. For now, if you’re interested in evidence-based medicine, parsimonious use of medical resources, and/or patient centered care, I encourage you to check it out. The one on coronary computed tomographic angiography (CCTA) included a reference to a NEJM letter by Drs. Schuur and Kosowsky that reads, in part,

CCTA did not improve patient safety. [Low risk] patients [] (rate of acute myocardial infarction or death during the index visit, <1%) who underwent CCTA were no less likely to have an acute myocardial infarction or cardiac death at 30 days than patients who received traditional care. CCTA only reduced the use of provider-discretionary health care services — admission to a hospital or an observation unit. CCTA may provide a psychological benefit to physicians, but it cannot be justified from a patient’s perspective. Patients who underwent CCTA were exposed to the risks of contrast-induced nephropathy and ionizing radiation. The use of CCTA led to the diagnosis of coronary artery disease — a radiologic diagnosis of unclear value — in 1 of 20 additional patients. How should clinicians explain this diagnostic strategy to patients? “Sir, although you only have a 1 in 100 chance of having a heart attack in the next month, I do not feel safe sending you home. So, I ordered an expensive test that will not reduce your risk of a heart attack, but it could cause kidney damage or cancer.” This is not “choosing wisely.” [Emphasis added.]

Shorter: It’s time to wake the f*** up.


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