Choosing wisely in cardiology: Five proposals from the Italian Association for Cardiovascular Prevention and Rehabilitation

Abstract

We do not always accomplish what is best for our patients. Is “more procedures, more drugs” a real synonym of good and always useful medicine? Probably not. Indeed, it has been highlighted that many tests and treatments, widely used in medical practice, do not bring benefits to patients, but can be harmful. So, why do we keep performing them? Many reasons, surely one of the main is the constant fear of malpractice legal-medical consequences; this led to the development of a defensive medicine, no longer focused on the health of the patient. For this reason, the Italian Association of Cardiac Prevention and Rehabilitation (GICR-IACPR) joined an international project “Choosing Wisely”, supported by the Slow Medicine Initiative, a network which states that “Less is more”. The purpose of the “Choosing Wisely” project is to improve the quality and safety of health services through the reduction of practices that, according to available scientific knowledge, do not bring significant benefits to the patients, but can, on the opposite, expose them to risks. This GICR-IACPR paper proposes to avoid five widespread practices in cardiology, at risk for inappropriateness and lacking of clinical evidence of benefit: i) do not perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery; ii) do not perform Computed Tomography for coronary calcium score in patients at high cardiovascular risk; iii) do not perform Holter electrocardiographic monitoring in patients suffering from syncope, near syncope or dizziness, in whom a non-arrhythmic origin has been documented; iv) do not routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding prophylaxis in patient with single drug antiplatelet therapy in absence of additional risk factors; v) avoid routine use of infective endocarditis prophylaxis in mild to moderate native valve disease.