Deciding which patients presenting with chest pain should undergo diagnostic coronary angiography (DCA) is an everyday dilemma for the cardiologist.  In the ARIA (Appropriateness of Referral and Invesigation of Angina) study, Hemingway and colleagues used scoring criteria, based on patient-specific characteristics and validated by 2 panels of experts made up of 22 UK physicians, in order to identify situations in which referral for DCA was made appropriately.

Among the 9,356 consecutive patients referred to 6 urban UK rapid-access clinics between 1996-2002, underuse of DCA when patients had an appropriate indication was common – DCA was performed on only 43.0% of patients deemed appropriate by panel A, and 28.7% of patients deemed appropriate by panel B.  Not undergoing DCA was associated with higher coronary event rates over a median follow up time of 3 years [adjusted HR 2.78 (panel A), 2.47 (panel B)].

Incorporating patient-specific appropriate scores into risk assessment algorithms may assist with clinical decision making and might improve appropriate service delivery.  Although further work remains to be done, such algorithms may eventually find a place in, for example, electronic patient records.

• Hemingway H, Chen R, Junghans C, et al.  Appropraiteness Criteria for Coronary Angiography in Angina: Reliability and Validity.  Ann Intern Med 2008;149:221-231.