By ANISH KOKA

A recent email that arrived in my in-box a few weeks ago from an academic hailed the latest “paradigm shift” in cardiology as it relates to the management of stable angina.  (Stable angina refers to chronic,non-accelerating chest pain with a moderate level of exertion).  The points made in the email were as follows (the order of the points made are preserved):

1. The financial burden of stress testing was significant (11 billion dollars per annum in the USA!)
2. For stable CAD, medical treatment is critical.  We now have better medical treatments than all prior trials including ischemia. these include PCKS9 Inhibitor, SGLT2-i, GLP1 agonists Vascepa and others
3. CTA coronaries is by far the most important single test for evaluation of these patients
4. ” the paradigm of ischemia testing may have come to an end”
5. For stable angina (not ACS!) in most cases, the decision on revascularization should be based only on symptoms alleviation (as no survival benefit).

The general public should find it interesting, and not a random coincidence that the first point immediately gets to the financial burden of stress testing in a communication that is supposed to assess the level of evidence for the management of coronary artery disease. Imagine a cardiologist enters your exam room to talk about the chest pain you get every time you run up a flight of steps, and starts off the conversation with how much the societal cost of stress tests are.  The cost of care is certainly a relevant concern, especially if it’s to be borne directly by the patient, but it would seem that the decision of whether a therapy is effective or not should be divorced from how much some bean counter decides to price the therapy to generate a certain return on investment.  As such, the discussion that follows will omit any consideration of cost when evaluating the new ‘paradigm shift’ in management of coronary disease that is apparently upon us.

This particular debate boils down to the relevance of diagnostic testing for coronary artery disease.  The traditional approach to testing is a functional test that utilizes the uptake of radioactive isotope injected into a patient during stress and rest conditions to identify mismatches in blood flow in the two states to identify myocardial ischemia.  The amount of ischemia can be quantified as percent of total myocardium, and has been well correlated with prognosis.  Having lots of ischemia typically means a much shorter lifeline than having little or no ischemia.  The accepted paradigm in Cardiology has been to use traditional stress testing to triage patients to ‘conservative’ medical therapy or an invasive approach to bypass or open arteries via stents or coronary bypass surgery.