Expensive Diagnostic Testing: Is It Now a Crime of the Heart? : Medicine: The angiogram may be a standard test for cardiac disease, but critics say it leads to unnecessary surgery.

In assessing heart disease and deciding how to treat it, physicians rely on the angiogram as the standard diagnostic test. More than 1 million angiograms--special X-rays showing the inside of blood vessels--are performed in the United States each year.

Based on the results of this test, surgeons performed 285,000 artery-clearing procedures called angioplasty and 380,000 heart bypass operations in 1990.

But are surgeons performing too many angiograms--possibly leading to unnecessary heart operations?

A small but provocative study in this month’s Journal of the American Medical Assn. by physicians from the Lown Cardiovascular Center in Brookline, Mass., zeroed in on the angiogram as the “critical choke point” on the road to the expensive and, at times, life-threatening angioplasty and bypass operations. Angioplasty runs about $7,000. Heart bypass surgery can cost $35,000--with a mortality rate of about 2%.

Thomas Graboys and colleagues at the Brookline center examined 168 patients with chest pains who decided on their own to get a second opinion about undergoing an angiogram. They concluded that perhaps 50% of all angiograms are unnecessary or could be safely postponed, with patients being monitored and taking medication for heart disease instead.

After four years, patients in the study who were judged not to require angiography had a low mortality rate from cardiac causes of 1.1%--lower than the average death rate of those undergoing bypass surgery.

But the head of the National Heart, Lung and Blood Institute and cardiologists who perform angiograms are alarmed by the study’s suggestion that a critical diagnostic test be tossed aside because of a perception that the test results encourage too much heart surgery.

Moreover, they said it was dangerous to extrapolate from the experiences of a very small and highly select group of patients.

“Graboys is describing a group of patients that was healthy enough to travel from one doctor’s office to another and enlist a number of different opinions about how their symptoms should be handled,” said Dr. Jeffrey M. Isner, a professor of medicine at Tufts Medical School and chief of cardiovascular research at St. Elizabeth’s Hospital in Boston. “Those patients are not representative of the average patient who gets admitted to a hospital with increasing chest pain in whom there’s a legitimate question whether the patient would be best served by surgery, angioplasty or medical therapy.”

Treadmill stress tests and medical histories may indicate heart disease but cannot show the extent of the problem, said Dr. Eric Topol, head of cardiology at the Cleveland Clinic. “And in women the treadmill test is notoriously inaccurate,” he said. The angiogram is needed “in order to go from yes or no to where are the blockages? How many are there? How severe are they?”

“Dr. Graboys is right that there are probably too many of these bypass and angioplasty procedures,” said Topol. “That doesn’t mean we should not do the angiogram.”

The study’s conclusion that angiograms automatically lead to too many heart procedures is flawed, they said. Graboys’ “point is, you get on the train and you can’t get off. My point is, you get on the train and get off at the next stop. You look, but you don’t touch,” said Topol.

In his article, Graboys spotlighted the fact that there has been no study examining the outcome for people randomly assigned to either get an angiogram or continued medical therapy and monitoring. A rigorously controlled study, he said, would have to involve thousands of patients and cost millions of dollars, with few results before the year 2000.

What’s more, according to Graboys, there is a dearth of information as well on whether bypass surgery and angioplasty actually prolong life in comparison to non-invasive therapies--or which of the two operations is better in the long term.

But, protested Claude J. Lenfant, head of the NHLBI, the angiogram “is not an end in itself; it’s just a way to make a decision.”

A report on “Sex Differences in the Management of Coronary Artery Disease” last year in the New England Journal of Medicine demonstrated that in some sense the angiogram does serve as the gatekeeper for surgical procedures.

The study showed that while men were twice as likely to undergo an invasive cardiac procedure as women, heart bypass surgery was performed with equal frequency among men and women who did have an angiogram. That is, once women’s symptoms were deemed serious enough to warrant an angiogram, they received more-aggressive treatment at the same rate as men.

At the same time, another study in the same issue showed that women hospitalized for coronary heart disease undergo fewer major diagnostic tests as well as fewer surgical procedures than men do. The authors cautioned that their findings could reflect either overuse of procedures for men or under-use for women.