Not so Fast: How to Avoid Bias Toward Stents in Managing SIHD

Jaya Mallidi, MD, MHS

"If he were your family member, would you still recommend medical therapy first?" the primary care physician asked with genuine concern over our mutual patient, Mr Simon.*

I had seen Mr Simon for evaluation of chest pain. He was a sturdy man who lived alone with his dog, Midge. His unkempt, long silver beard made him look older than his age of 66 years. For at least 6 months, he has been having chest pain when taking Midge on long walks. He had a stress test 3 days before his visit with me. On treadmill, he walked for 7 minutes, and the imaging study showed a mild area of ischemia in the inferior wall. He had chronic stable angina or stable ischemic heart disease (SIHD).

He was not taking any medications. "I don't like taking pills, and so avoid seeing doctors," he said defiantly. Over the next hour, we discussed his diagnosis, treatment options, and importance of medication compliance. By the end of our conversation, he was willing to take aspirin and beta-blockers. "That's a good start," I said, smiling and advised him to come back to reevaluate in a few weeks.

Two days later, I got the call from his primary care physician asking why coronary angiography was not considered.