Practice Patterns for Outpatients With Stable Coronary Artery Disease: A Case Vignette-based Survey Among French Cardiologists

• When not guided by clear recommendations, routine decisions for CAD patients vary considerably among cardiologists
• Although the final decision is partly associated with cardiologists' profiles, it remains largely unexplainedIn an attempt to assess practice patterns regarding routine management of patients with stable coronary artery disease, a survey was sent to all cardiologists of a geographical area in France. The response rate was high (92%). Our results show that practice patterns vary considerably when not guided by high-level recommendations. Overall, cardiologists were more likely to use diagnostic tests or therapies despite the absence of a rational scientific basis, than to adopt more ‘conservative’ attitudes. Although certain physician characteristics (age, gender, sub-specialty, and type of practice) were associated with management patterns, the final decision remains largely unexplained.

BackgroundAlthough medical management of patients with coronary artery disease (CAD) is often based on scientific guidelines, a number of everyday clinical situations are not specifically covered by recommendations or the level of evidence is low. The aim of this study was to assess practice patterns regarding routine management of patients with stable CAD.MethodsA survey comprising six questions on two clinical scenarios regarding stable CAD management was sent to 345 cardiologists from the Nord-Pas-de-Calais Region (France). We first assessed practice patterns globally and then searched for associations with physician characteristics (age, gender, sub-specialty, and type of practice).FindingsThe response rate was 92%. Regarding management of asymptomatic CAD, 86% of the cardiologists performed routine exercise testing, before which, 69% withdrew β-blockers. After a positive exercise test, 26% immediately performed coronary angiography and 67%, further imaging tests. In the absence of left ventricular dysfunction or history of myocardial infarction, routine β-blocker prescription for stable CAD was selected by 43%. When anticoagulation was needed for atrial fibrillation, 41% initiated direct oral anticoagulants rather than vitamin-K antagonists and 50% combined aspirin with anticoagulants. For recurrent stable angina in patients with known CAD, 24% performed coronary angiography directly, 49% requested a stress test, and 27% opted for medical therapy without further diagnostic testing. Age, gender of the cardiologist, academic environment, and practice of interventional cardiology were associated with certain management patterns.InterpretationWhen not guided by high-level recommendations, practice patterns for routine clinical situations in stable CAD vary considerably. Future clinical trials should address these clinical interrogations.