Cardiovascular Medicine

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

High-Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Cardiovascular Medicine section of MKSAP 16.

  • Cardiac stress testing is most useful in patients with an intermediate probability of disease, in whom a positive test significantly increases disease likelihood and a negative test significantly decreases likelihood; do not perform cardiac stress testing in patients with either a low or a high pretest probability of disease (see Question 1 and Question 82).
  • Do not perform coronary artery calcium scoring in asymptomatic patients at very low or very high risk of a coronary event.
  • Reserve cardiac stress tests with imaging (echocardiographic or nuclear) for patients who are unable to exercise or have abnormalities on their resting electrocardiogram that may interfere with test interpretation (see Question 28, Question 92, Question 107, and Question 115).
  • Do not obtain echocardiography in asymptomatic patients with innocent-sounding heart murmurs, typically grade 1/6 or 2/6 short systolic mid-peaking murmurs that are audible along the left sternal border (see Question 3).
  • Perform coronary angiography in patients with a history of chronic stable angina in the setting of progressive symptoms despite optimal medical therapy, difficulty tolerating medical therapy, or high-risk findings on exercise testing; there is no role for routine periodic cardiac catheterization in patients with chronic stable angina and well-controlled symptoms as it has not been shown to improve outcomes and carries risk (see Question 99).
  • Do not order routine stress testing or routine electrocardiography for asymptomatic patients following successful percutaneous coronary intervention.
  • Do not order serial echocardiography for the assessment of chronic heart failure unless the patient’s clinical status changes.
  • Reserve the B-type natriuretic peptide (BNP) test to differentiate between a cardiac and pulmonary cause of dyspnea when the diagnosis is unclear; do not routinely measure BNP in patients with typical signs and symptoms of heart failure.
  • In patients who develop heart block following a myocardial infarction, delay the decision to implant a permanent pacemaker for several days to determine whether the heart block is transient or permanent.
  • Do not prescribe antibiotic prophylaxis before any procedure (including dental procedures) in patients with native valvular disease unless there is a history of endocarditis.
  • Perform echocardiography in patients with known mild aortic stenosis in the setting of new or progressive symptoms, but do not obtain routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3 to 5 years.
  • Do not routinely repeat echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function.
  • Avoid combination treatment with an antiplatelet agent and warfarin for the treatment of peripheral arterial disease because it is no more effective than antiplatelet therapy alone and carries a higher risk of life-threatening bleeding.
  • Treat patients with stable claudication symptoms with medical therapy and exercise and not percutaneous or surgical revascularization because the rate of progression to critical limb ischemia and limb loss is less than 5% annually (see Question 91).
  • Do not refer asymptomatic patients for patent foramen ovale closure to prevent stroke because the available procedures are not effective.
  • Do screen asymptomatic men aged 65 to 75 years who have ever smoked with a one-time abdominal ultrasonographic screening to look for abdominal aortic aneurysm; do not repeat this screening after a normal study.