The Stable Patient and the Counted Procedure: What a Cardiologist Owes When the Hospital Is Keeping Score

The Stable Patient and the Counted Procedure

Imagine you are the cardiologist. Your patient is in his fifties and his condition is stable. He has no heart attack and no chest pain that stops him working. His angiogram shows a narrowing. He looks at you and says: Doctor, do whatever is needed. Your hospital tracks procedure volume and your department's numbers are reviewed every month. Placing the stent is the easy option. The patient expects it, the hospital rewards it and nobody will question you. But the evidence does not support it.

What the

evidence says The ISCHEMIA trial, published in The New England Journal of Medicine in 2020, enrolled 5,179 patients with stable coronary disease and moderate to severe ischemia at 320 sites in 37 countries. Patients were assigned either to an initial invasive strategy or to optimal medical therapy, with revascularisation kept for those who had an acute event or angina.

At a median of 3.2 years and again at five years, there was no significant difference in the main outcome and death rates were similar. A stent treats one narrowing. It does not cure atherosclerosis or remove the risk of a future heart attack.

An angiogram shows anatomy. It does not by itself show that a narrowing needs a stent.

Why both choices cost something Not stenting is not free for you.

The patient may feel under-treated and go to another hospital that will stent him. Your procedure numbers will fall in a hospital that counts them. And if he has a heart attack next year, even one the evidence says a stent would not have prevented, people may say you failed him.

Stenting is not free for him. He takes on the risks of an invasive procedure and its cost, his family pays and his lasting protection still has to come from the medicines and lifestyle changes he needed anyway.

The principle that decides it Non-maleficence comes first.

Do not expose a patient to the risks and costs of a procedure that the best available evidence says will not improve his outcome. Informed consent comes next. Do whatever is needed is not consent. It is trust given to you and that trust is exactly what a fee-for-procedure system can exploit. Professional autonomy means your judgment is free from the hospital's spreadsheet, not that you are free to go along with it.

The decision Do not place the stent today.

Start optimal medical therapy. Explain the ISCHEMIA findings plainly, offer a second opinion and record his informed choice. Tell him stenting remains an option if angina persists and limits his life. Then raise the volume incentive formally, so that the next doctor does not face the same pressure.

You will pay for this decision in lost procedures, in your department's displeasure and possibly in losing this patient to someone less careful. That cost is what it takes to keep the patient's interest first.