American College of Physicians: Internal Medicine — Doctors for Adults ®


In the News
for the Week of 6-24-08


  • Highlights of ENDO 08 conference
  • New legislation may stop scheduled Medicare cuts
  • Demand for primary care docs spikes but pay keeps supply low

Health information technology

  • Physicians slow to adopt EHRs, citing cost


  • Two-way link found between diabetes and depression


  • Rhythm control found no better than rate control in heart failure


  • Young blacks experiencing fewer injuries, suicides; rate among whites increasing

FDA updates

MKSAP quiz: cardiac evaluation

  • MKSAP quiz returns to ACP Internist

Government news

  • CMS will begin sending quality bonus payments in July
  • Potential exposure to lead in artificial turf

From ACP Internist

  • What they're saying on the blogs

From the College

  • Master becomes the AMA’s second woman president
  • ACP revises ethics policy on complaints procedures
  • Chapter awardees named

Cartoon caption contest


Highlights of ENDO 2008 conference

SAN FRANCISCO—Diabetes and testosterone studies topped the news at ENDO 08, the Endocrine Society’s 90th annual meeting held last week. Among the research of interest to internists:

  • Women with type 2 diabetes and heart disease get less intensive medical treatment for, and have poorer control of, these two conditions than men. In a study of nearly 45,000 diabetics, the comorbid women were 44% more likely than the comorbid men to have high LDL, but 15% less likely to get lipid-lowering medication. The women were also 19% more likely to have uncontrolled hypertension, and 15% more likely to have poor long-term control of their blood glucose levels. The findings may explain why death from heart disease has decreased among diabetic men in the past 25 years, but hasn't decreased for diabetic women, the study’s lead author said.
  • For obese and overweight men with type 2 diabetes, moderate fitness levels lowered the risk of all-cause death by 40%-50% during an average follow-up of seven years. By measuring peak metabolic rate during a standard treadmill exercise tolerance test, researchers classified fitness levels as low, moderate or high. Moderate fitness reduced death risk by 40% in healthy-weight and overweight men, and 52% in obese men, while high fitness level reduced death risk by 60% in healthy-weight men, and 65% in overweight men. The results suggest all diabetics, regardless of weight, should achieve and maintain at least a moderate fitness level, a study co-author said.
  • Men with erectile dysfunction should be screened for testosterone deficiency and metabolic syndrome, because the conditions often occur together. In a study of 771 men who sought treatment for erectile dysfunction, 18.3% of men had testosterone deficiency that had previously been undetected. In addition, 35% had type 1 or 2 diabetes, 31% had hypertension, 21% had dyslipidemia and 14% had coronary heart disease. In several of these cases, the men received these diagnoses for the first time.
  • A study of nearly 2,000 German men found that those with low testosterone levels had more than 2.5 times the risk of dying in the next decade compared to men with higher testosterone—a difference that wasn’t explained by age, smoking, alcohol use, exercise or waist circumference. In cause-specific analysis, low testosterone predicted a higher risk of death due to cardiovascular disease and cancer, specifically. Since it’s likely that lifestyle helps determines testosterone levels, the study’s lead author urged men to control their weight and exercise and eat healthfully.

—By senior writer Jessica Berthold

For more coverage from the conference, see the ACP Internist blog.


New legislation may stop scheduled Medicare cuts

On Friday the House of Representatives introduced new legislation that would avert the physician payment cuts scheduled for July 1. The Medicare Improvements for Patients and Providers Act of 2008 (HR 6331) would continue current Medicare payment rates through the end of 2008 and provide for a 1.1% update on Jan. 1, 2009. In addition, the bill would also provide additional benefits for primary care, including increased payments for office visits and increased funding for the Medicare medical home demonstration project.

HR 6331 was introduced by Representatives Charles Rangel (D-NY) and John Dingell (D-MI). It is a companion bill to S. 3101, legislation that was introduced by Sen. Max Baucus (D-MT) previously. The Senate legislation came to a vote on June 12, but failed to reach the 60 votes (cloture) needed to allow the Senate to proceed to consideration of the bill.

The scheduled cuts are due to the flawed sustainable growth rate (SGR) formula that is used to calculate Medicare payments to physicians. In December, Congress passed legislation that prevented a scheduled Jan. 1, 2008 payment cut. However, the legislation only provided for the first six months of 2008 and, without other legislation, Medicare payments for the last half of 2008 will be calculated using the SGR formula.

Congressional leaders from both parties have indicated that they support preventing the cuts and replacing them with a positive update to physician payments. They have also indicated support for other measures that ACP would like to have included in any new legislation introduced to prevent the cuts. Among them are increased payments for internists’ office visits and increased funding for a medical home demonstration project.

CMS has said that as long as legislation to stop the cuts is signed into law by July 1, the agency will be able to process claims submitted on or after that date with the new rates. CMS has said that it will not allow physicians to make a mid-year change in their Medicare participation status. The next opportunity to change participation status will be in mid-November when CMS expects the 2009 participation decision period to begin.

Although the legislative situation remains unresolved, ACP is doing everything possible to persuade Congress to replace the cuts with positive updates and include other needed changes to improve payments for internists’ services.

For the latest up-to-the minute news about this legislation, ACP’s efforts and what to expect from Medicare payments beginning on July 1, please visit the ACP Advocacy Web page.


Demand for primary care docs spikes but pay keeps supply low

Demand for family physicians and general internists intensified during 2008 as more physicians opted to pursue careers in higher-paying specialties, said the latest survey from recruiting firm Merritt, Hawkins & Associates.

Family practitioners topped the list of searches by specialty with 492 searches during the 12-month review period (up 62% over 2006-07), followed by general internists at 314 searches (up 87%) and hospitalists at 208 searches (up 93%), said a June 17 Merritt Hawkins news release. The report is based on 3,146 nationwide physician searches conducted from April 1, 2007 to March 31, 2008.

Average salaries offered primary care physicians during the review period were $176,000 for general internists, $181,000 for hospitalists and $172,000 for family practitioners. Average salaries for family practitioners and general internists have increased by 19% and 9%, respectively, since 2005-06.

The comparatively low salaries are dissuading many students from choosing primary care, said the report, especially when average salaries for some specialists are significantly higher. The average for orthopedic surgeons, for example, was $439,000 and radiologists averaged $401,000. Nurses trained in administering anesthesia (CRNAs) also had higher average pay than primary care physicians at $185,000.

Of the total physician search assignments reviewed in the report, 45% were for hospital employment, up from 19% three years ago. Signing bonuses were offered as a recruiting incentive in 74% of the search assignments, up from 46% three years ago.

A complete copy of the report is available on Merritt, Hawkins’ Web site.


Health information technology

Physicians slow to adopt EHRs, citing cost

U.S. physicians have been slow to adopt electronic health records (EHRs), mostly citing cost as a barrier.

National estimates of EHR use by physicians range from 9% to 29%, but reliable data are lacking. So researchers supported by the Department of Health and Human Services surveyed physicians and reported the results of 2,758 responses in the June 18 online edition of the New England Journal of Medicine.

They found that 4% of respondents had fully functioning EHRs that:

  • record patients' clinical and demographic data,
  • view and manage lab and imaging results,
  • manage order entry (including electronic prescriptions), and
  • support clinical decisions, including warnings about drug interactions or contraindications.

Another 13% had basic systems that didn’t have order-entry capabilities or clinical-decision support.

Electronic records were more common among those who worked in large or primary practices, or worked in medical centers or hospitals. Groups of 50 or more doctors were three times as likely to have a basic EHR and more than four times as likely to have a fully functional system than physicians in groups of three or fewer. Overall, though, only 17% of physicians in large groups had a fully functional system, and 49% in large groups had no EHR.

Among physicians who did not have an EHR, the most commonly cited barriers to adoption were capital costs (66%), not finding a system that met their needs (54%), uncertainty about their return on the investment (50%), and concern that a system would become obsolete (44%).

The New England Journal of Medicine study is online.

ACP announced last week an EHR Partners Program.

Paul Felden, ACP Member, of Mt. Laurel, N.J., told the New York Times why he hasn’t gone paperless.

Richard Baron, FACP, was quoted in the Wall Street Journal’s health blog about the costs, and how implementing EHRs disrupted every office system.




Two-way link found between diabetes and depression

Patients with depression may be more likely to develop diabetes, and patients who have been diagnosed with type 2 diabetes are more likely to have depressive symptoms, a new study found.

Researchers used data from the Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort of more than 6,800 men and women aged 45 to 84 years. They analyzed study participants’ depressive symptoms, as measured by a Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or higher, and glucose levels. Participants were divided into those with normal fasting glucose, impaired fasting glucose, and type 2 diabetes.

The study found a modest association of baseline depressive symptoms with incident type 2 diabetes. The association persisted even when controlled for metabolic, inflammatory, and socioeconomic factors, although it was no longer statistically significant after adjustment for lifestyle factors. A stronger association was found in the odds of a patient who had been diagnosed with type 2 diabetes having depressive symptoms (hazard ratio, 1.54). However, patients with impaired fasting glucose or undiagnosed diabetes were less likely than average to be depressed.

Researchers noted that the poor health behaviors common among depressed people could explain much of that depression-to-diabetes link. The diabetes-to-depression association could be evidence of the psychological stress associated with diabetes management as well as a result of the complications and comorbidities of diabetes. The study was published in the June 18 Journal of the American Medical Association.

The authors suggested that future research should determine whether interventions to modify behavioral factors associated with depression could assist in diabetes prevention. They also recommended that clinicians consider routine screening for depression symptoms among patients diagnosed with type 2 diabetes.

The study is online.




Rhythm control found no better than rate control in heart failure

Patients with heart failure and atrial fibrillation survive just as well on rate control therapy as rhythm control, a new study found.

The randomized trial included 1,376 patients who had a left ventricular ejection fraction of 35% or less, symptoms of congestive heart failure and a history of atrial fibrillation. Patients were randomized to either rate or rhythm control and followed for a mean of 37 months. On the study’s primary outcome, death from cardiovascular causes, 27% of the rhythm-control group died, compared to 25% in the rate-control population. The groups had similar rates of death from any cause, stroke, worsening heart failure and composite outcomes.

Researchers concluded that, contrary to their hypothesis, rhythm control does not reduce the rate of death and that rate control should be considered a primary approach for patients with atrial fibrillation and congestive heart failure. They cautioned that their results could not be generalized to patients with heart failure and preserved left ventricular function. The study was published in the June 19 New England Journal of Medicine.

An accompanying editorial noted that the study’s findings probably indicate the shortcomings of current antiarrhythmic therapies, rather than proof of the absence of benefit from maintaining a sinus rhythm. The editorialist said that new therapies, particularly catheter ablation, could eliminate the low efficacy and high toxicity that are currently associated with antiarrhythmic therapy.

The study and the editorial are online.




Young blacks experiencing fewer injuries, suicides; rate among whites increasing

Injury-related deaths among blacks ages 15 to 24 decreased between 1999 and 2005, while injury-related deaths among whites increased, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health.

The study found that between 1999 and 2005 injury-related deaths among black males experienced a steady decline, while the injury death rate among white males increased by 7%. When compared with rates in 1999, the gap between injury rates of black males and white males decreased by 24%.

Using a Web-based injury statistics system, as well as mortality data from several agencies, researchers examined injury mortality rates among Americans between the ages of 15 and 24. Mortality resulting from the 10 most common causes of injury-related death was analyzed by race, sex, age, type of injury and state.

The reduction in racial disparity resulted from a decrease in motor vehicle crashes and firearm suicides among black males and an increase in suicide by suffocation (typically hanging) and unintentional poisoning (such as a drug overdose) among white males. Among young women, black females experienced a decrease in the rate of firearm suicide, while white females experienced an increase in unintentional poisoning and suicidal suffocation.

The total injury mortality rate among whites did not change significantly; however, there was an 11% decrease among blacks. In two of the 10 injury categories, unintentional poisoning among males and hanging among females, increases both doubled.

The study was published in the June 2008 issue of Injury Prevention and was funded by a grant from the CDC's Center for Injury Research and Prevention. An abstract is online.


FDA updates

Boxed warnings added to conventional antipsychotics

Conventional antipsychotics will now be required to carry a boxed warning about the risk of death associated with their off-label use in patients with dementia, the FDA announced last week.

Conventional antipsychotics will carry the same warning as atypical antipsychotics, which received a boxed warning in 2005. The new language warns that clinical studies indicate that antipsychotic drugs of both types are associated with an increased risk of death when used in elderly patients treated for dementia-related psychosis.

The change is based on two recent observational epidemiological studies which compared elderly patients’ risk of death on conventional antipsychotics, atypical antipsychotics and no antipsychotics, an FDA press release said. Labeling on the atypical drugs will be changed so that both types of medication carry uniform warning language.

A list of the affected medications is online.


Diaphragm-pacing device approved

The implantable electronic device which allowed actor Christopher Reeve to spend time off a ventilator was approved last week by the FDA.

The NeuRx DPS RA/4 Respiratory Stimulation System uses electrodes implanted in the muscle of the diaphragm to stimulate contraction and allow some spinal cord injury patients to breathe without a ventilator for at least four hours a day. The FDA approved the device under a Humanitarian Device Exemption, an approval process for devices which treat or diagnose conditions affecting fewer than 4,000 people per year.

A multi-center trial found the device to be safe and have a probable benefit to patients, an FDA press release said. The device manufacturer is working on expanding the use of the device to patients with amyotrophic lateral sclerosis, a company representative told the June 18 Washington Post.

The FDA release is online. The Washington Post is online.


Warnings issued on fake cancer cures

The FDA has cracked down on sellers of fake cancer cures, issuing warning letters to 23 U.S. companies and two foreign individuals who have marketed products that claim to prevent and cure cancer.

The products include tablets, teas, tonics, black salves and creams and contain ingredients such as bloodroot, shark cartilage, coral calcium, cesium, ellagic acid, cat’s claw and mushrooms. The products are marketed through the Internet and violate FDA regulations by claiming to cure, treat, mitigate or prevent disease.

Examples of the fraudulent claims include:

  • “Causes cancer cells to commit suicide!”
  • “80% more effective than the world’s number one cancer drug”
  • “Avoid painful surgery, radiotherapy, chemotherapy, or other conventional treatments”

A list of the products and a consumer article about health scams are online.


MKSAP quiz: cardiac evaluation

MKSAP quiz returns to ACP Internist

ACP Internist has brought back its MKSAP quiz. This popular feature was so heavily requested by our readers that we’re restoring it weekly in our e-mail updates.

Case study:

A 64-year-old woman is evaluated for chest pain and shortness of breath. Over the past two to three months, she has noticed exertional dyspnea and a decline in her exercise tolerance. With more significant exertion, such as climbing one to two flights of stairs, she experiences a midepigastric tightness with associated discomfort in the left side of her neck and jaw, which improves with rest. She has had no nocturnal symptoms. Her weight has not increased and she denies edema.

The patient has dyslipidemia and hypertension. She is overweight and leads a sedentary lifestyle. She is a nonsmoker. Medications include daily low-dose aspirin, hydrochlorothiazide and pravastatin. Her family history includes myocardial infarction in two brothers, one at age 56 years and the other at age 62 years.

On physical examination, her pulse is 64/min, respiration rate is 12/min, and blood pressure is 136/88 mm Hg. BMI is 37.0. On cardiac examination, carotid upstrokes are brisk. There is no jugular venous distention. Cardiovascular point of maximal impulse is not palpable. There is a normal S1 and a physiologically split S2. No murmurs are heard. Abdominal examination is significant for adiposity but is otherwise benign. There is no pedal edema. Troponin T level is 0.07 ng/mL (0.07 µg/L).

Electrocardiogram is shown. (Click to view large size)

Small EEG image

Which of the following is the most appropriate next step in the evaluation of this patient?

A. Cardiac MRI
B. Coronary angiography
C. Coronary CT angiography
D. Transesophageal echocardiogram
E. Treadmill perfusion stress scintigraphy

Click here or scroll to the bottom of the page for the correct answer.


Government news

CMS will begin sending quality bonus payments in July

The Centers for Medicare & Medicaid Services will begin distributing bonus payments beginning July 14 for physicians who participated in the 2007 Physician Quality Reporting Initiative (PQRI).

Physicians who satisfactorily completed the requirements of the program will begin receiving their payments as group remittances sent to their practice using their tax identification number. Around the same time physicians will also be able to access feedback reports about the data they reported for 2007.

Under the PQRI program, physicians may qualify for incentive payments by reporting to CMS on quality measures they provide to Medicare beneficiaries. The 2007 PQRI was conducted from July 1 to Dec. 31, 2007, and all data had to be submitted by Feb. 29, 2008. Physicians who successfully reported on the quality measures could earn a bonus payment of up to 1.5% of provided Medicare services for that time period.

Physicians still interested in qualifying for the payment bonus but who haven’t reported data can use an alternative reporting method to qualify for the second half of 2008. Further information about the PQRI is available on the CMS Web site.


Potential exposure to lead in artificial turf

After high levels of lead were discovered in an artificial turf field in New Jersey, the Centers for Disease Control and Prevention (CDC) issued a public health advisory about potentially unhealthy levels of lead dust in artificial turf.

A limited sampling of athletic fields in New Jersey and commercial products indicates that artificial turf made of nylon or nylon/polyethylene blend fibers contains levels of lead that pose a potential public health concern, said a June 19 CDC advisory. Artificial turf fields made with only polyethylene fibers showed very low levels of lead.

While the risk of harmful lead exposure is low from new fields with intact fibers, the CDC said, a hazard may be posed as fields that are old, that are used frequently, and that are exposed to the weather break down into dust as the turf fibers are worn or demonstrate progressive signs of weathering, including fibers that are abraded, faded or broken.

So far, no cases of elevated blood lead levels in children have been linked to artificial turf on athletic fields in New Jersey or elsewhere. The CDC will provide further public health recommendations on the issue pending an investigation by the U.S. Consumer Product Safety Commission.

The CDC alert and more information about lead exposure are online.


From ACP Internist

What they're saying on the blogs

Join the ACP Internist's community on its blogs, featuring daily updates on news that just can't wait. Get all the breaking news from ENDO 08 in San Francisco. From basic research to weight loss to hormone replacement therapy, we’ve got it covered.


From the College

Master becomes the AMA’s second woman president

Nancy H. Nielsen, MACP, a board-certified internist from Buffalo, N.Y., and senior associate dean for medical education at the School of Medicine and Biomedical Sciences at the University of Buffalo, was inaugurated last week as the 163rd president of the American Medical Association (AMA). She is the second woman to hold the AMA’s highest elected office.

Dr. Nielsen served four consecutive annual terms as speaker of the House of Delegates, the AMA policy-setting body, and three consecutive annual terms as vice-speaker. She has been an active contributor to organized medicine’s policy discussions and has held several important positions. During her two terms on the AMA's Council on Scientific Affairs, she helped develop policy on public health issues such as alcoholism among women, colorectal cancer screening and safety in dispensing prescriptions.

Dr. Nielsen also acts as an AMA representative or liaison to a number of outside groups focused on enhancing the quality of medical care, including the AMA-convened Physician Consortium for Performance Improvement and the National Quality Forum.

ACP Internist's profile of Dr. Nielsen is online.


ACP revises ethics policy on complaints procedures

The College has modified its ethics policy to include a timely notification clause near the end of section 1. The section now reads "The complainant and the member against whom the complaint was brought will be informed on a periodic basis of the status of the complaint."

The entire ethics policy is online.


Chapter awardees named

ACP chapters honor Members, Fellows and Masters of ACP who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research or service to their community, their chapter and ACP. Awardees are physicians with a long history of excellence and peer approval in the specialty of internal medicine. In recognition of their outstanding service, these exceptional individuals received chapter awards in April, May and June 2008:


Dennis G. Delgado, FACP, Birmingham, Laureate Award
Billy Willard Boyd, FACP, Montgomery, Laureate Award
William A. Curry, FACP, Birmingham, Chapter Advocacy Award

Atlantic Provinces

Mahesh Raju, FACP, Saint John, NB, Laureate Award


Hiroyuki Ide, ACP Member, Kamakura Kanagawa, Volunteerism & Community Service Award

Rhode Island

Edward A. Iannuccilli, FACP, Bristol, Irving Addison Beck Award
Kenneth H. Mayer, FACP, Providence, Milton Hamolsky Lifetime Achievement Award
Michael B. Macko, ACP Member, Providence, Governor’s Award


Jose E. Moros, FACP, Barquisimeto Lara, Laureate Award
Eduardo Morales, FACP, Miami, Volunteerism & Community Service Award


Robert J. Davis, II, FACP, Cheyenne, Laureate Award


Cartoon caption contest

June's winning entry

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Colin Carracher, a third-year medical student at the University of Cincinnati College of Medicine. He will receive a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history. ACP readers cast 180 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:


"And no one thought to get a potassium level?"

The winning caption received 36.1% of the votes cast. The three runners up were:

“You guessed it, universal health coverage” (27.8%)
“This patient is a perfect candidate for a banana bag.” (24.4%)
“Who’s the curious one, now?” (11.7%)



MKSAP answer

B. The most appropriate next step for this patient is a coronary angiography. Her symptoms have typical features for angina. She describes exertional dyspnea and lower chest (midepigastric) tightness which radiates to her left jaw. This occurs with physical activity and resolves with rest. Her troponin T level is normal and her electrocardiogram shows nondiagnostic ST-T wave changes. A key factor in selecting a diagnostic modality for the initial diagnosis of coronary artery disease is the estimation of pretest probability. This patient’s age (>60 years) and typical anginal complaints confer a high pretest probability (>90%) of disease. Coronary angiography provides definitive diagnosis of coronary artery disease with direct assessment of the coronary artery lumen and also provides the means for therapeutic intervention (percutaneous intervention) if a culprit lesion is identified.

Cardiac MRI and CT angiography are rapidly developing technologies for the noninvasive, direct visualization of the heart and coronary arteries. Cardiac MRI and CT angiography are increasing in clinical availability despite the absence, to date, of clear indications for these modalities. Available data demonstrate good diagnostic accuracy for CT angiography and cardiac MRI, but these data are drawn from single-center studies using experienced readers evaluating patients with a higher pretest likelihood of disease. Therefore, the accuracy of these modalities for use in risk stratification in patients with a low pretest likelihood of disease is less clear. Because of evolving technology and unclear diagnostic accuracy for general applications, CT angiography and cardiac MRI are not currently considered equivalent alternatives to standard coronary angiography and neither modality is recommended for screening patients.

Appropriateness criteria for CT angiography and cardiac MRI have been recently published. Because the entire heart is in the imaging plane, CT angiography and cardiac MRI are most useful for evaluation of intra- and extracardiac structures and congenital or acquired coronary anomalies, particularly anomalous coronary artery take-offs. These modalities are also useful as an adjunct when images from standard coronary angiography are suboptimal, such as in the assessment of coronary artery bypass grafts if the ostia were unable to be engaged, or visualization of coronary arteries distal to totally occluded stenoses. However, only the more proximal portions of the coronary artery arteries (generally to the mid vessel) can be reliably evaluated with CT angiography and cardiac MRI.

For CT angiography, the presence of severe coronary calcification or intracoronary stents may limit evaluation by obscuring the coronary artery lumen. As with standard coronary angiography, the use of iodinated contrast is required. Advantages of cardiac MRI include the absence of exposure to radiation or iodinated contrast media. In addition, because coronary artery calcification is not prominent on cardiac MRI images, detection of lesions in heavily calcified coronary segments or in-stent stenosis is more reliable. However, published data suggest slightly lower overall diagnostic accuracy with cardiac MRI compared with CT angiography. As with other MR imaging, cardiac MRI is relatively contraindicated in the presence of larger medical devices made of metal.

A transesophageal echocardiogram may provide improved resting images over a transthoracic study in an obese patient, but is not used as an initial test for ischemia evaluation. Cardiac stress testing with transesophageal echocardiography imaging is not generally performed. A resting transthoracic echocardiogram could be considered as an adjunct to coronary angiography for concurrent evaluation of this patient’s dyspnea, but does not supplant coronary angiography for the diagnosis of stenoses.

Stress testing with or without an imaging modality is the traditional noninvasive approach to detecting coronary artery disease. Stress testing identifies hemodynamically significant disease by demonstrating characteristic electrocardiographic changes, myocardial perfusion defects by scintigraphy, or regional wall motion abnormalities by echocardiography. These changes are interpreted as surrogate markers of a significant stenosis because the coronary artery is not directly visualized. In symptomatic patients with a high pretest probability of disease, coronary angiography is preferred over noninvasive stress testing because a negative study result in a patient with ongoing, persistent symptoms has a high likelihood of being falsely negative and does not provide the opportunity for immediate therapeutic intervention. If a patient such as the one in this question were to have a negative stress test, but continue to have a similar symptom profile, the results would likely be looked upon with skepticism.

Key Points
  • Symptomatic patients with a 90% or higher pretest probability of disease should proceed directly to coronary angiography.
  • CT angiography and cardiac MRI provide noninvasive, direct visualization of the heart and coronary arteries but are not currently considered equivalent alternatives to standard coronary angiography.
  • CT angiography and cardiac MRI are most useful when images from standard coronary angiography are suboptimal or for evaluation of congenital or acquired coronary anomalies.

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