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The risks of inappropriateness in cardiac imaging.

Picano E - Int J Environ Res Public Health (2009)

Bottom Line: Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome.Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war.Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

View Article: PubMed Central - PubMed

Affiliation: Institute of Clinical Physiology, CNR, Pisa, Italy. picano@ifc.cnr.it

ABSTRACT
The immense clinical and scientific benefits of cardiovascular imaging are well-established, but are also true that 30 to 50% of all examinations are partially or totally inappropriate. Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome. Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war. After a long journey across imaging laboratories, he will have stress echo, myocardial perfusion scintigraphy, PET-CT, 64-slice CT, and adenosine-MRI performed, with a cumulative cost of >100 times a simple exercise-electrocardiography test and a cumulative radiation dose of >4,000 chest x-rays, with a cancer risk of 1 in 100. Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

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Related in: MedlinePlus

Ulysses’ voyage as a metaphor for the diagnostic pathway of the patient with suspected coronary artery disease. At the end of the first round of this odyssey, the cumulative cost is more than 100 times a simple exercise-electrocardiography. The cumulative radiation dose is that of more than 4,000 chest x-rays. The cumulative damage (including acute, subacute, and long-term risks) will cause a serious health detriment (including infarction, renal insufficiency, or cancer) in about 5–10% of patients.
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f2-ijerph-06-01649: Ulysses’ voyage as a metaphor for the diagnostic pathway of the patient with suspected coronary artery disease. At the end of the first round of this odyssey, the cumulative cost is more than 100 times a simple exercise-electrocardiography. The cumulative radiation dose is that of more than 4,000 chest x-rays. The cumulative damage (including acute, subacute, and long-term risks) will cause a serious health detriment (including infarction, renal insufficiency, or cancer) in about 5–10% of patients.

Mentions: The Ulysses syndrome was first described in 1972 by Canadian physician Dr. Mercer Rang, who applied it to the ill effects of extensive diagnostic investigations conducted because of a false-positive or indeterminate result in the course of a routine laboratory screening [18]. Ulysses left Troy in full physical and psychological health. Equipped with a safe ship and a competent crew, he was sure he would return home quickly; instead it turned out that he lost all his crew, his ship and he was able to make it home only after a journey full of hardships. Today, the most frequent diagnostic investigation is a cardiac imaging test. Mr. Ulysses, a typical middle-aged “worried-well” asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war (Figure 2). In an asymptomatic patient, routine screening even with a simple exercise testing is not indicated (class III). The indication is IIB (weak supportive evidence) for asymptomatic men older than 45 years with multiple risk factors and/or who are involved in occupations in which impairment might impact public safety, according to 2003 recommendations of the American College of Cardiology/American Heart Association [19]. The family physician directly refers the patient to the cardiologist (step 2) who suggests a transthoracic echocardiogram (step 3), which is perfectly normal, but with poor visualization of segment 17, the true apex. The patient is again sent to the echo lab to repeat the transthoracic echo with echo-contrast injection (step 4): the apex is perfectly visualized and looks normal. However, just to be on the safe side, the cardiologist suggests a multislice computed tomography (step 5). Ulysses accepts enthusiastically since he recently read the front page and cover story of Time Magazine (September 5, 2005) explaining that in this way you can detect asymptomatic life-threatening coronary artery stenosis. The scan shows only minor luminal irregularities of very uncertain pathological meaning. At this point, thallium stress perfusion scintigraphy (step 6) is performed. A very mild, questionable hypoperfusion of the infero-basal wall is documented. The stress echo (step 7) is performed and a very mild apical hypokinesis is observed at peak exercise in presence of marked systolic blood pressure rise. At this point the cardiologist asks for further examinations and Mr. Ulysses is becoming increasingly anxious. One after another, Ulysses undergoes a PET-adenosine stress (step 8: marginally positive at basal lateral wall) and MRI adenosine with gadolinium contrast (step 9: marginally positive on the basal inferior septum). The patient is eventually referred to coronary angiography (step 10); the island of Ithaca is crowded with non-significant coronary stenoses, unrelated to perfusion defects or wall motion abnormalities, which may, however, trigger the oculo-stenotic reflex [10] leading to the vicious circle of angioplasty (obviously with drug-eluting stent), imaging test for the diagnosis of silent re-stenosis, presence of perfusion or wall motion defects, re-angiography, and so on and so forth.


The risks of inappropriateness in cardiac imaging.

Picano E - Int J Environ Res Public Health (2009)

Ulysses’ voyage as a metaphor for the diagnostic pathway of the patient with suspected coronary artery disease. At the end of the first round of this odyssey, the cumulative cost is more than 100 times a simple exercise-electrocardiography. The cumulative radiation dose is that of more than 4,000 chest x-rays. The cumulative damage (including acute, subacute, and long-term risks) will cause a serious health detriment (including infarction, renal insufficiency, or cancer) in about 5–10% of patients.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC2697934&req=5

f2-ijerph-06-01649: Ulysses’ voyage as a metaphor for the diagnostic pathway of the patient with suspected coronary artery disease. At the end of the first round of this odyssey, the cumulative cost is more than 100 times a simple exercise-electrocardiography. The cumulative radiation dose is that of more than 4,000 chest x-rays. The cumulative damage (including acute, subacute, and long-term risks) will cause a serious health detriment (including infarction, renal insufficiency, or cancer) in about 5–10% of patients.
Mentions: The Ulysses syndrome was first described in 1972 by Canadian physician Dr. Mercer Rang, who applied it to the ill effects of extensive diagnostic investigations conducted because of a false-positive or indeterminate result in the course of a routine laboratory screening [18]. Ulysses left Troy in full physical and psychological health. Equipped with a safe ship and a competent crew, he was sure he would return home quickly; instead it turned out that he lost all his crew, his ship and he was able to make it home only after a journey full of hardships. Today, the most frequent diagnostic investigation is a cardiac imaging test. Mr. Ulysses, a typical middle-aged “worried-well” asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war (Figure 2). In an asymptomatic patient, routine screening even with a simple exercise testing is not indicated (class III). The indication is IIB (weak supportive evidence) for asymptomatic men older than 45 years with multiple risk factors and/or who are involved in occupations in which impairment might impact public safety, according to 2003 recommendations of the American College of Cardiology/American Heart Association [19]. The family physician directly refers the patient to the cardiologist (step 2) who suggests a transthoracic echocardiogram (step 3), which is perfectly normal, but with poor visualization of segment 17, the true apex. The patient is again sent to the echo lab to repeat the transthoracic echo with echo-contrast injection (step 4): the apex is perfectly visualized and looks normal. However, just to be on the safe side, the cardiologist suggests a multislice computed tomography (step 5). Ulysses accepts enthusiastically since he recently read the front page and cover story of Time Magazine (September 5, 2005) explaining that in this way you can detect asymptomatic life-threatening coronary artery stenosis. The scan shows only minor luminal irregularities of very uncertain pathological meaning. At this point, thallium stress perfusion scintigraphy (step 6) is performed. A very mild, questionable hypoperfusion of the infero-basal wall is documented. The stress echo (step 7) is performed and a very mild apical hypokinesis is observed at peak exercise in presence of marked systolic blood pressure rise. At this point the cardiologist asks for further examinations and Mr. Ulysses is becoming increasingly anxious. One after another, Ulysses undergoes a PET-adenosine stress (step 8: marginally positive at basal lateral wall) and MRI adenosine with gadolinium contrast (step 9: marginally positive on the basal inferior septum). The patient is eventually referred to coronary angiography (step 10); the island of Ithaca is crowded with non-significant coronary stenoses, unrelated to perfusion defects or wall motion abnormalities, which may, however, trigger the oculo-stenotic reflex [10] leading to the vicious circle of angioplasty (obviously with drug-eluting stent), imaging test for the diagnosis of silent re-stenosis, presence of perfusion or wall motion defects, re-angiography, and so on and so forth.

Bottom Line: Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome.Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war.Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

View Article: PubMed Central - PubMed

Affiliation: Institute of Clinical Physiology, CNR, Pisa, Italy. picano@ifc.cnr.it

ABSTRACT
The immense clinical and scientific benefits of cardiovascular imaging are well-established, but are also true that 30 to 50% of all examinations are partially or totally inappropriate. Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome. Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war. After a long journey across imaging laboratories, he will have stress echo, myocardial perfusion scintigraphy, PET-CT, 64-slice CT, and adenosine-MRI performed, with a cumulative cost of >100 times a simple exercise-electrocardiography test and a cumulative radiation dose of >4,000 chest x-rays, with a cancer risk of 1 in 100. Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

Show MeSH
Related in: MedlinePlus