Current ACC/AHA guidelines recommend that in patients with stable angina, noninvasive testing is used to prove mild or moderate ischaemia prior to performing PCI.

Lin et al. performed a retrospective analysis of 23,887 patients who had undergone elective PCI, of whom 44.5% (10,629) underwent stress testing within 90 days prior to PCI.  A wide regional variation (22.1% to 70.6% was seen, and four factors in particular were linked to a decreased likelihood of stress testing: female sex (adjusted odds ratio [AOR], 0.91), age 85 years or over (AOR, 0.83), a history of congestive hear failure (AOR, 0.85), and a history of prior PCI (AOR, 0.45).  Patients with chest pain (AOR, 1.28) and of black race (AOR, 1.26) were more likely to have stress tests prior to PCI.  Lastly, patients treated by physicians performing >150 PCI procedures a year were less likely to receive stress testing.

Inappropriate procedures not only pose a risk to patients, but generate unnecessary costs and waste time.  Furthermore, current Medicare proposals suggest rewarding only those physicians and hospitals that adhere to guidelines.  This paper suggest that many patients are not being adequately investigated prior to PCI.

• Lin GA, Dudley RA, Lucas Fl et al.  Frequency of Stress Testing to Document Ischemia Prior to Elective Percutaneous Coronary Intervention.  JAMA 2008;300(15):1765-1773