Percutaneous coronary intervention, or PCI is the clinical name for angioplasty and cardiac stenting. The procedure is used to open narrowed coronary arteries in patients suffering from chronic chest pain. According to current guidelines by the American College of Cardiology, the American Heart Association and the Society for Cardiovascular Angiography and Intervention, heart patients need to undergo a stress test to determine whether they need angioplasty. The test shows if the arteries are so clogged that there is a severe decrease in blood supply to the heart.

However, according to a study published in the Journal of the American Medical Association, less than half of all Americans who undergo non-emergency artery-opening procedures for heart disease get the recommended cardiac stress tests.

For the study, researchers from the University of California-San Francisco, the Maine Medical Center and the Dartmouth-Hitchcock Medical Center analyzed data from a random sample of nearly 24,000 Medicare patients 65 years of age or older, who had elective PCI at US hospitals during 2004. They found that only 44.5 percent of those surveyed took a stress test on a treadmill within 90 days of their elective surgery. The figures varied significantly depending on the hospital patients were referred to (with rates ranging from a low of 22.1 percent to a high of 70.6 percent), on patients characteristics and the age of doctors doing the PCI.

PCI coast Medicare $10,000 to $15,000 per procedure and has contributed significantly to increases in Medicare spending since the mid-1990s. More than 1.2 million PCIs are performed annually in the US, according to the American Heart Association. The bad part is that such procedures are no better at stopping heart attacks and deaths than medications, according to previous research.

“We need to look at how we’re spending our money and can we spend it more wisely with a better return on our investment in health care. Right now, we have a system that pays the same for inappropriate and appropriate care. There should be a restructuring of incentives,” Rita Redberg, a professor of medicine at the University of California San Francisco, and an author of the JAMA study, said.

When it comes to reasons of why stress tests weren’t performed, the researchers could not find a clear answer. There were cases when doctors performed another test called coronary angiography, which uses special dye and X-rays to identify the artery blockages. In other cases, doctors provided PCIs because the patients had a family history of the disease and considered the procedure necessary. Another reason could be that current guidelines are not as clear as they should be.

“That situation may be clarified by new guidelines expected to be released shortly by the American College of Cardiology. The college is about to release appropriateness criteria that say that in such-and-such a situation, a PCI would be appropriate,” said Dr. Redberg.