Restricting nuclear cardiac stress testing in favor of stress echocardiography

Dr. William Follansbee is the chairman of the American College of Cardiology/American Society of Nuclear Cardiology (ACC/ASNC) task force on non-invasive cardiac imaging and the director of nuclear cardiology at the University of Pittsburgh Medical Center Cardiovascular Institute.

He recently published an editorial in the Pittsburgh Post Gazette in which he criticized the local Blue Cross/Blue Shield carrier, Highmark, for restricting the use of nuclear cardiac stress testing in favor of sonographic cardiac stress testing (a.k.a. stress echocardiography). Dr. Follansbee made several arguments as to why he believed that Highmark’s restriction of nuclear cardiac stress testing was wrong.

One of his core arguments is that “patients will be … denied access to appropriately indicated nuclear cardiology tests ordered by their physicians.” He (indirectly) references the ACC’s 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging in support of this argument. This document identifies clinical scenarios where a group of experts reached consensus that nuclear cardiac stress testing was appropriate.

Dr. Follansbee fails to mention that the ACC also publishes an analogous document called 2008 Appropriateness Criteria for Stress Echocardiography,which uses the same methodology to identify clinical scenarios where a group of experts reached consensus that sonographic cardiac stress testing was appropriate and which illustrates that indications and test performance characteristics for nuclear and echocardiographic stress testing are virtually the same. That said, neither of these ACC documents explicitly identifies where nuclear cardiac stress testing is preferable to sonographic cardiac stress testing and vice versa.

Appropriateness criteria give a semblance of objectivity as to when cardiac stress testing is indicated, but since there are many situations in which the ACC suggests that both nuclear and echocardiographic stress testing are indicated, they give no explicit guidance on which modality is preferred in a situation in which when they are both indicated. The question that doctors like me actually need answered is two-fold: For a given clinical situation 1) is a cardiac stress test indicated and 2) should I order a nuclear or echocardiographic stress test?

Since the ACC cardiac stress testing appropriateness criteria guidelines did not address which testing modality is preferred where they are both indicated, Highmark did. Although Highmark’s answer apparently did not meet Dr. Follansbee’s approval, their preference of sonographic over nuclear cardiac stress testing actually makes a lot of sense.

All other things being equal, a safer test is preferable to a riskier test, and a less expensive test is preferable to a more expensive test. Guess what? With respect to “all other things,” nuclear and sonographic cardiac stress testing are essentially equal; even the ACC’s appropriateness criteria say so: “The overwhelming majority of final ratings of cardiac RNI [i.e., nuclear stress testing] and stress echocardiography [i.e., sonographic stress testing] were concordant for similar clinical indications.” Nuclear and sonographic cardiac stress testing have nearly identical sensitivities and specificities; if anything, the specificity of sonographic cardiac stress testing even seems to be somewhat better.

Guess what else? Sonographic cardiac stress testing is safer than nuclear cardiac stress testing because it does not use carcinogenic ionizing radiation, and sonographic cardiac stress testing is significantly less expensive than nuclear cardiac stress testing. As such, Highmark’s preference of sonographic cardiac stress testing over nuclear cardiac stress testing is appropriate.

It’s no longer news that America’s health care costs are high and rising with no improvement in our mediocre quality. Through its justified preference of sonographic to nuclear cardiac stress testing, Highmark has identified a way to safely improve (or at worst not decrease) quality and simultaneously decrease cost. This is win-win and a powerful example of comparative effectiveness research, although not referred to as such. I do not know whose interests Dr. Follansbee primarily had at heart in arguing for less safe, more expensive, and no more accurate nuclear cardiac stress testing over sonographic cardiac stress testing, but it seems to me that it was neither individual patients nor society at large. Regardless, the ACC should issue a guideline that explicitly states when sonographic cardiac stress testing is preferred to nuclear and vice versa. Sure, this would likely anger many cardiologists and nuclear medicine physicians who make a nice living performing nuclear stress testing, but we should practice medicine with our patients’ best interests primarily at heart, not our own.

Adam Rothschild is a family physician and the CEO of Doctrelo.  He blogs at The Doctrelo Blog.


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  • CSmith MD

    This post might not generate much interest, but it should. Stress echocardiography is essentially equivalent to nuclear cardiac stress testing. The biggest differences are (1) echos don’t expose the patient to levels of radiation equal to several hundred xrays (2) stress echos require more effort on the part of the cardiologist and are much less lucrative (3) nuclear testing is many times more common when a physician owns the equipment.
    In a nutshell, stress echos could be utilized over 90% of the time, are safer and cheaper, but it’s often not in the financial best interest of the ordering physician to do so.

  • Marc Gorayeb, MD

    Thanks for piqueing my interest in this topic. Now if you didn’t have a political agenda, you could have also educated me by presenting both sides of the issue. A two-second internet search yielded the following information. I haven’t verified it, and it may or may not be valid. But it sounds reasonable to me:
    Echo is quicker, cheaper, and provides information on valvular function as well as myocardial function.
    However, images are inadequate in up to 15% or so of patients, such as those with COPD, chest deformities, obesity, and some who have previously sustained myocardial damage.
    Do us all a favor; if you decide to advocate eliminating a diagnostic or therapeutic modality from American medicine, then please provide us with a scientifically well-reasoned justification.

    • Adam Rothschild, M.D., M.A.

      I’m confused by your comment, Marc. What did I write that isn’t scientifically well-reasoned? Also, while I readily admit that I have an agenda (i.e., to increase the quality and decrease the cost of health care in America), to what “political agenda” do you refer?