Current Clinical Practice Is Different
This article (1) reminds me of the year 2002, when Dissmann and de Ridder in an article in the Lancet (2) denounced exactly what has at last been taken up as the subject of this guideline. Actual clinical practice in cardiology has absolutely no overlap with this guideline. Coronary angiograms and interventions without objective confirmation of ischemia or clinical relevance are elements of routine clinical practice for economic reasons. GPs are thus deprived of any way of exerting influence. One is likely to look in vain for the particular piece of patient information entitled “Do I need cardiac catheterization?” (3) in most cardiology clinics and practices.
Some passages are contradictory. The Marburg Heart Score is recommended for GPs, but this deviates in some items from what is shown in Table 2 in the article. But the real question is: do we need all these calculations in routine clinical practice? As the article cautiously says: “When interpreting these score results, it is important to take the overall clinical picture into account.” Why should I conduct ergometry testing only when the pre-test probability is 15–30% if ultimately (luckily) it is clinical assessment that dominates?
Experience shows that ergometry during follow-up care does not allow for estimating the progression of coronary health disease with certainty, but it provides useful clues regarding physical conditioning, so as to identify weaknesses in the treatment, influence a patient’s lifestyle, and reduce fears.
In the meantime, it has become easier in many places to obtain an appointment for cardiac catheterization than for ergometry. But this takes me back to the start of my argument.
Dr. med. Herbert Wollmann
Innere Medizin/Kardiologie, Hausärztliches MVZ-Stendal
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Albus C, Barkhausen J, Fleck E, Haasenritter J, Lindner O, Silber S on behalf of the German National Disease Management Guideline “Chronic CHD” development group: Clinical practice guideline: The diagnosis of chronic coronary heart disease. Dtsch Arztebl Int 2017; 114: 712–9 VOLLTEXT|
|2.||Dissmann W, de Ridder M: The soft science of German cardiology. Lancet 2002; 359: 2027–9 CrossRef|
|3.||BÄK, KBV, AWMF: Verdacht auf koronare Herzkrankheit: Brauche ich eine Herzkatheter-Untersuchung? Patienteninformation des ÄZQ zur NVL Chronische KHK I. www.patienten-information.de/kurzinformationen/herz-und-gefaesse/khk-4aufl-vers1-eh1 (last accessed on 11 January 2018).|