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BMJ 2008; 337 doi: (Published 21 October 2008) Cite this as: BMJ 2008;337:a2177

US doctors ignore guidelines on stress tests before PCI

US guidelines require objective evidence of ischaemia, usually some kind of stress test, before a percutaneous coronary intervention (PCI) in patients with stable coronary artery disease. A study from the US using data from Medicare suggests that fewer than half such patients had a stress test before their PCI in 2004.

Researchers found documentary evidence of a stress test in only 10 629 out of a sample of 23 887 adults over 65 who had an elective PCI that year (44.5%). Some regions did better than others. Rates of stress testing varied between 22.1% and 70.6% across the US. Women, very old people, and those with heart failure or a previous history of cardiac catheterisation were significantly less likely than others to be tested for ischaemia. So were those treated by experienced doctors who performed more than 150 PCIs each year. Angina was the only clinical factor associated with an increased chance of a stress test.

The low overall rates and general variation in practice matter because we know that elective PCI works best for patients with documented ischaemia associated with the coronary artery due to be dilated, say the authors. Clearer guidelines would help, adds an editorial (p 1817). So would reimbursement policies that reward evidence based practice.

Don’t rely on the food industry to prevent obesity

In Western style capitalist economies, the food industry is driven to put profit margins and the dividends of shareholders ahead of consumer health. Those motives will never change, and they put the industry into direct conflict with the urgent public health agenda on obesity, write two experts. Highly processed unhealthy foods and drinks are more profitable than fruit, vegetables, and water. Companies such as McDonald’s and Coca Cola cannot market healthy food and drink without fundamentally undermining their business model. They improve their corporate image by sponsoring sports, conducting research, and …

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