June 17, 2020
Why don't we take good advice?
As healthcare practitioners, we have all seen countless patients for whom small lifestyle changes offer a path to significant improvements in their disease management and quality of life. However, for one reason or another, those small adjustments remain beyond their reach, even when they understand the potential personal value of the change.
Research on what drives us to change has shown that we incorporate additional data and viewpoints when considering a change for someone else, but are less likely to do the same if the change to be made is our own.
Two recent publications highlighted how this struggle with change is seen in cath labs on a daily basis, specifically around the benefits of making physiology-driven revascularization decisions yet the relative infrequency with which physiologic information is acquired.
One study included 18,000 stable patients sent to cath labs in Veterans Health Administration facilities in the US. It found that using invasive FFR to guide revascularization decisions was associated with a 43% lower risk of all-cause mortality at 1 year, when compared to cases guided only by angiography. “Angiographically intermediate lesions” were found in all of these patients, yet clinicians only used invasive FFR on 16.5% of cases.
Another study looked at nearly 24,000 stable patients who underwent PCI in Sweden. Again, FFR-guided revascularization decisions were associated with a significant reduction (19%) in all-cause mortality at 1 year when compared to patients whose PCI was only angiographically guided. But again, invasive FFR was used in only 15.4% of cases.
These vast data sets force us to ask questions regarding why clinical methods that are shown to improve patient outcomes are not more widely utilized. If we encourage our patients to make lifestyle changes that, based on both common sense and clinical data, will likely improve their long-term outcomes, why do we struggle to adjust our own clinical practice in order to meet that same goal?
Whether physiology is assessed with a pressure wire, is derived from an invasive angiogram, or is performed completely non-invasively via a coronary CTA and the HeartFlow FFRCT Analysis, the message that physiology-guided revascularization is better for patients is clear and being recognized around the world. But it is a change that requires a shift in practice as we work to overcome the clinical bias of the “ocular-stenotic reflex.”
So as we ask patients to make lifestyle modifications or adhere to a new drug regimen, let us also make a commitment to shift our own behavior as well. The evidence is clear that incorporating physiology in decision making about revascularization results in better outcomes and longer lives for our patients. By making this shift, we can ensure we are doing our part to help patients manage their coronary disease optimally.