In Volume 2 of the JOURNAL, tWO articles described the impact of stress myocardial perfusion imaging on the subsequent use of coronary angiography. a,2 The combined number of patients evaluated in these two retrospective studies was more than 6000. Based on an extremely low likelihood of coronary events in people with negative stress perfusion imaging, coronary angiography was performed in only between 3% to 4% of patients with a negative study results. These studies were performed in both outpatient and inpatient clinical settings consistent with current modes of routine practice. Follow-up of presumed low-risk patients who were managed conservatively indicated excellent outcomes.
Despite the potential for self-referral, nuclear studies served to limit rather than promote overuse of invasive cardiologic diagnostic procedures. Although not prospectively designed clinical trials, these studies point the way to our future. Based on such studies, it is appropriate to consider radionuclide stress myocardial perfusion imaging as a major potential gatekeeper for the performance of diagnostic coronary angiography.
A recent conversation on this issue with a close friend and colleague helped me focus on several important implications of such gatekeeping status. Clearly, a responsible and thoughtful gatekeeper can position nuclear cardiology at a critical decisionmaking point with respect to managed care. As we enter an era dominated by paradigms of costeffectiveness and incentives for doing less rather than the traditional fee for service paradigm, the judicious use of outpatient nuclear testing to determine suitability for further detailed invasive evaluation can certainly limit the performance of multiple procedures and curtail expense in appropriate patients. This treatment strategy algorithm should be evaluated further in well-designed prospective trials.
In addition, the gatekeeping role places before nuclear cardiology the opportunity to develop new substantial partnerships and relationships with those responsible for producing and developing effective