Imaging Dominates ACC’s Top 5 Overused Procedures, Tests

The American College of Cardiology (ACC) has released a list of 5 recommendations to help cardiologists avoid treatments and tests that lack the support of guidelines or appropriate use criteria. Cardiac stress testing and advanced noninvasive imaging are identified in the April 4, 2012, announcement as among the worst offenders, while stenting beyond the culprit lesion in primary percutaneous coronary intervention (PCI) is also cited as inappropriate.

The ACC joined 8 other medical specialty societies in highlighting tests and procedures that are widely used but, by evidence-based standards, unnecessary. The effort is part of the American Board of Internal Medicine’s Choosing Wisely campaign, which is aimed at promoting physician-patient conversations that can improve outcomes, avoid unnecessary or harmful interventions, and reduce health care costs.

In particular, the ACC urges clinicians to avoid:

  • Cardiac imaging tests, particularly stress tests or advanced noninvasive imaging, if there are no symptoms of heart disease or high-risk factors like diabetes or peripheral arterial disease
  • Performing such tests as part of a routine annual follow-up in patients with no change in signs or symptoms
  • Performing the tests prior to low-risk surgery unrelated to heart disease
  • Using cardiac echocardiography as routine follow-up in adults with mild heart valve disease who have had no change in signs or symptoms
  • Stenting nonculprit lesions in patients undergoing primary PCI

‘Right Care at the Right Time’

“We believe that providing quality care guided by the latest research and guidelines is the best way to manage health care resources,” ACC senior vice president James W. Fasules, MD, said in a press release. “Informed conversations between physicians and patients are a critical element of quality care. . . . More care is not always better care. We support the right care at the right time.”

From an interventional standpoint, David A. Cox, MD, of Lehigh Valley Hospital (Allentown, PA), said the recommendations are “spot on” with current guidelines.

“Most of us have sort of woken up to the idea that doing the culprit infarct artery makes the most sense. If you’ve got other disease, even though it looks pretty tight, you just defer it. The safest thing is to do it at some other point,” he told TCTMD in a telephone interview.

The recommendations that focus on imaging are “interesting,” he said, because “there’s never been a guideline that’s ever approved a surveillance exercise test after a PCI.” He added that physicians who have been ordering certain tests should “pause and think hard about what the indications . . . are. I think a great majority of the echos that are done for surveillance and the exercise tests of asymptomatic patients probably don’t need to be done.” 

The challenge, though, lies in finding the right balance between quality care and rising health care costs, Dr. Cox said. “[W]e have to be careful that these guidelines and recommendations aren’t chiseled stone and that there’s some clinical equipoise, if you will.”

Ultimately, Dr. Cox envisions that these recommendations will give patients the necessary means to improve their own care. “[E]veryone trusts the cardiologist, but sometimes there just aren’t good data to support what you’re doing,” he concluded. “So in this age of appropriate care with appropriate cost, I think it’s great for patients to at least raise the question: Do I need this test?”


The American College of Cardiology releases list of commonly used—but not always necessary—tests or procedures [press release]. Published April 4, 2012. Accessed April 10, 2012.



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  • Dr. Cox reports no relevant conflicts of interest.