title: Is cardiac catheterization necessary before initial management of patients with stable ischemic heart disease? Results from a Web-based survey of cardiologists.
abstract: BACKGROUND
  It is unknown whether preconceived beliefs regarding the need for cardiac catheterization and revascularization in patients with stable ischemic heart disease (SIHD) would preclude a study randomizing patients with significant ischemia to a conservative strategy. Given the widespread practice of performing revascularization in patients with SIHD, we assessed the feasibility of conducting a randomized trial comparing initial invasive and conservative strategies in patients with SIHD and moderate or severe ischemia.
  
  
  METHODS
  An online survey to cardiologists queried their willingness to enroll a sample patient with frequent stable angina, >10% myocardial ischemia, and normal ejection fraction into a randomized trial with a 50% chance of being conservatively managed without cardiac catheterization.
  
  
  RESULTS
  Among 499 respondents, 57% (95% CI 53%-62%) were willing to enroll the patient. Among 207 cardiologists unwilling to enroll, 55% (95% CI 48%-61%) would be willing if they knew the patient did not have very high-risk features on stress imaging, yielding a total of 80% (95% CI 76%-83%) of cardiologists willing to enroll. No differences were observed among different types of cardiologists (interventional, invasive/noninterventional, and noninvasive). Seventy-one percent (95% CI 67%-75%) were more likely to try initial medical therapy after the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results.
  
  
  CONCLUSIONS
  Most surveyed cardiologists were willing to enroll SIHD patients with at least moderate ischemia into a trial with an initial noninvasive strategy arm. These findings support the feasibility of planning a large-scale trial to test the role of cardiac catheterization and revascularization in the initial management of SIHD patients with moderate or severe ischemia.
authors.affiliation: Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA. david.maron@vanderbilt.edu
authors.forename: David J
authors.initials: DJ
authors.lastname: Maron
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.forename: G B John
authors.initials: GB
authors.lastname: Mancini
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Scott
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Byrne
authors.forename: Frank E
authors.initials: FE
authors.lastname: Harrell
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.forename: Rory
authors.initials: R
authors.lastname: Hachamovitch
authors.forename: William E
authors.initials: WE
authors.lastname: Boden
authors.forename: William S
authors.initials: WS
authors.lastname: Weintraub
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
mesh_terms: D000328:Adult; D006328:Cardiac Catheterization; D002309:Cardiology; D005240:Feasibility Studies; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic