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Abstract: Patients who are tested for heart diseases should make sure an angiogram is not the first test given because the procedure may be harmful in some cases. Suggestions for selecting specialists, hospitals and doctors are provided.
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In his new book The Best Medicine, Robert Arnot, M.D., CBS News medical correspondent, discusses a number of common operations and procedures, rating each on its likelihood of being performed unnecessarily. The rating for angiogram (a test to assess the severity of heart disease): "Very High." Here's how to avoid the procedure when it's really not indicated -- and how, when it is, to find the best hospital and doctor.

An angiogram that is performed unnecessarily carries two types of danger: the very real risks of the procedure itself--stroke, heart attack, or death--and the risk that it will be followed by another inappropriate operation or procedure. I have seen this happen countless times. A patient goes to a doctor for a minor complaint. The doctor then orders a routine stress test. The result is equivocal. Without any classic signs or symptoms of heart disease, an angiogram is ordered. Any patient who progresses from an initial office visit through stress testing, then to an angiogram and a possible bypass operation, should consider each successive step carefully to ensure that surgery does not become a self-fulfilling prophecy. In 1991, the research firm MediQual reported that 35.26 percent of the coronary-artery angiograms they studied had none of the objective clinical findings they use to validate an angiogram.

Most of the inappropriate procedures are performed on patients who fail to undergo other diagnostic tests first. A good rule of thumb to remember is: Make sure your first elective test is not an angiogram.

WHAT THE PROCEDURE IS

The cardiologist makes a small, temporary hole in a major artery in your arm or leg. Into that hole he or she passes a long, thin tube called a catheter. The catheter is threaded up into a coronary artery. Once the catheter is in place, a liquid containing special material that an X-ray device can "see" is injected into the coronary artery being studied. A series of images are made as the fluid flows through the artery.

An angiogram is the single most accurate test to assess the severity of coronary-artery disease. It allows doctors to peer inside coronary arteries and locate blockages that may cause chest pains, heart attack, or death. Doctors can then decide if those blockages should be bypassed through surgery, pushed aside by angioplasty, or treated by other methods. Doctors use angiograms to plot treatment strategy. Can they see a good clean stretch of artery into which to sew a new blood vessel during bypass surgery? Is there a solitary blockage that can be pushed aside using a dilating balloon device called an angioplasty catheter?

Angiograms are also used to evaluate other problems: poorly functioning heart muscles; diseased or damaged heart valves; congenital heart defects; coronary-artery-bypass grafts; and abnormal openings between an artery and vein (called an arteriovenous fistula) or between different sides of the heart (known as septal defects)--openings that usually are a congenital problem but may develop after a major heart attack.

HOW TO PROTECT YOURSELF

Step 1: Make sure you need the procedure. The following list of diagnoses, based on guidelines from the American College of Cardiology, shows conditions that justify an angiogram.

Diagnosis: Doctors suspect you have coronary-artery disease. Although you have no physical symptoms of heart disease, a stress test indicates the existence of coronary-artery disease. But since stress tests are notoriously inaccurate, additional tests should strongly confirm the diagnosis before you agree to an angiogram (see Step 2, page 71). People in certain occupations--such as an airline pilot, bus or truck driver, air-traffic controller, fire fighter, or athlete--may be required to have an angiogram in order to prove that heart disease is not present. This happens most often because of the unreliability of stress tests. If you are in this situation, you should exhaust all other diagnostic tests, including a reevaluation at a top cardiac teaching hospital, before agreeing to an angiogram.

Diagnosis: You have known coronary heart disease. If you have coronary-artery disease and are facing heart surgery, your doctor should order an angiogram in these situations: before major vascular surgery if there is intermittent chest pain (angina pectoris); if there are disruptions in the supply of blood of the heart (myocardial ischemia); or if your surgical risk can't be assessed by alternative methods because of other diseases.

Diagnosis: You have atypical chest pain of uncertain origin. An angiogram may be performed if your doctor suspects that the pain is caused by coronary-artery spasm or abnormal functioning of the left ventricle, the heart's main pumping chamber. This may be the case if congestive heart failure exists.

Diagnosis: You've just had a heart attack. Angiograms may be necessary after a heart attack if chest pain continues or if there was major damage to the heart structure. An angiogram is NOT appropriate under the following conditions:

* as a diagnostic test for coronary-artery disease, unless stress and other screening tests have been performed first.
* after bypass surgery or angioplasty, unless there are indications that the heart isn't getting enough oxygen
* terminal cancer, lung, kidney, or liver disease
* recent stroke
* increasing loss of kidney function
* bleeding in the stomach or intestine
* fever whose possible cause is an infection
* in the presence of an active infection
* severe anemia
* uncontrolled high blood pressure
* a serious noncardiac illness with an uncertain prognosis
* psychosis that makes patient's condition unstable during the procedure
* over age 80 unless medical therapy is absolutely failing
* when no treatment will be undertaken even if results show a problem
* overall unstable condition when no cardiac surgical team is available in the hospital (see Step 4, page 73)
* overdose of the drug digitalis
* documented allergies, called anaphylactic reactions, to the contrast fluid in an angiogram (patient still can be
premedicated with steroids to undergo procedure if the problem is life-threatening)
* extremely poor heart function with no physical symptoms of heart disease, unless there are real surgical
alternatives, such as a transplant.
* irregular heartbeat without other symptoms and with good stress-test results and no suggestion of an
aneurysm
* mild chest pain that is not worsening
* atypical chest pain without clear-cut signs of insufficient blood supply to the heart and with an earlier, normal angiogram.

These factors increase risk even if an angiogram is appropriate:

* abnormal blood pressure or sharp EKG changes during a stress test at a relatively low heart rate
* critical narrowing of the left main coronary artery detected on one or more diagnostic tests
* 90-percent blockages in the three main coronary arteries
* several diseased arteries and the heart's pumping capacity reduced to 35 percent of normal
* critical narrowing (stenosis) of the aortic valve.

Step 2: Consider an alternative. Before you have an angiogram, a heart scan should show strong evidence of heart disease. Although scans can't show the actual arteries, they can determine if your heart is pumping adequately and can indicate the parts of the heart muscle that aren't getting enough blood. A scan is like a photograph of a river delta taken from outer space. You may not be able to see the river, but if the surrounding area is green and thriving, you can assume that water is reaching the surrounding fields; if it is brown, the area is dry and fallow.

As scans have improved technically, they have been able to provide increasingly well-defined studies of the heart.

Step 3: Get a specialist's opinion. You will need an expert opinion if your angiogram is not clearly indicated, if you do not have a high chance of success, or if you want to consider an alternative. See a board- certified cardiologist. You have a choice between an invasive cardiologist who actually performs angiograms and a cardiologist who specializes in noninvasive approaches such as stress tests and cardiac scans. Discuss with this doctor the alternatives to an angiogram, and ask him or her to carefully review your medical history and tests to be certain your condition is correctly diagnosed. If time, expense, or travel problems prohibit you from seeking a specialist's opinion, learn as much as you can by calling a center of excellence (see "Centers of Excellence for Cardiology," page 73) or one of the following organizations:

American Heart Association (7272 Greenville Ave., Dallas, TX 75231; 214-373-6300). Your local chapter can recommend physicians. These centers, however, may not distinguish among physicians other than by their basic qualifications. National headquarters can send you booklets and may help you find a local phone number.

American College of Cardiology (9111 Old Georgetown Rd., Bethesda, MD 20814-1699; 800-253- 4636). This medical-specialty society publishes guidelines on cardiac care.

Coronary Club (Cleveland Clinic Foundation, 9500 Euclid Ave., Rm. E3-37, Cleveland, OH 44195; 216- 444-3690). This club publishes a monthly newsletter, Heartline, and has 10 chapters across the U.S.

Mended Hearts (7272 Greenville Ave., Dallas, TX 75231; 214-706-1442). With more then 200 chapters nationwide, this organization is an excellent source of information about bypass surgery and other heart operations. Members visit heart patients before and after surgery.

Step 4: Choose a hospital. An angiogram should be performed in a hospital. While there are independent laboratories, neither the American College of Cardiology nor the American Hospital Association approves of their use for angiograms. If complications develop, you could need immediate open-heart surgery that can be done only in a hospital. (If the procedure is being performed on a child, it should be done in a center that specializes in pediatric cardiology with surgeons on staff who limit their practices to children in a similar age range with congenital heart disease.)

An angiogram should be performed in an emergency only if it's a prelude to surgery or angioplasty. For that reason, you should be admitted to the hospital where surgery will be performed. I was involved in a recent case where the patient, a woman with unstable angina, was admitted to a small hospital. The angiogram was scheduled for several days later. If it revealed blockages, she would have to be transferred to a center that specializes in cardiovascular disease. I advised the family to make the transfer even before the angiogram was done. At the Cleveland Clinic, a center of excellence for cardiology, the angiogram showed a large blockage in a main coronary artery. Angioplasty pushed aside the blockage and relieved her chest pain. The principle is simple: At the earliest hint of trouble, put yourself into the care of the best possible medical center where all the options will be covered.

The hospital should perform a minimum of 300 angiograms a year. According to the American College of Cardiology, the hospital's mortality rate should not exceed 0.13 percent. The complication rate from stroke, heart attack, or hemorrhaging should be no greater then 0.5 percent.

Step 5: Choose a doctor.

Your doctor should be a board-certified cardiologist who has completed a three year fellowship in the field. That fellowship should have included a year in a catheterization lab, during which the doctor performed a minimum of 300 catheterizations with 200 of those as the primary operator. (Not all cardiology fellowships emphasize proficiency. In fact, the majority of fellows will not perform 300 procedures.)

Your doctor should currently perform a minimum of three catheterizations a week or about 150 a year. But if the doctor is performing more than 1,000 a year, that's too many--he or she isn't spending enough time on patient care. (Pediatric cardiologists need perform fewer angiograms--about 50 to 100 a year-- to maintain their skills.) The doctor's death rate should compare favorably to the average, which is about 0.13 percent; complication rate from stroke, heart attack, or death within 48 hours of the procedure should be less then 0.2 percent.

You should also ask the doctor how many of his or her patients have had the procedure a second time. Angiograms sometimes are repeated because the studies were inadequate or because the equipment was technically inferior. If this happens even once, it is too often.