exercise and the heart The Exercise Test as Gatekeeper *

The evaluation of a patient with a history suggestive of coronary artery disease is familiar to any internist. After a careful history and physical examination, the internist often turns to exercise testing to provide further diagnostic information. If the patient has an abnormal test result, the physician is faced with deciding whether to refer the patient for more invasive testing and therapy. There should be specific reasons to send a patient with stable angina to cardiac catheterization. Cardiac catheterization is a procedure that provides anatomic rather than functional information. Thus, the major reason to catheterize a patient is to assess whether the patient has the appropriate anatomy for invasive therapy, including coronary artery bypass surgery and percutaneous transluminal coronary angioplasty. In deciding which patient to refer for catheterization, the internist should evaluate whether the patient has a higher risk of mortality from the invasive procedures than from medical management. If the answer to this question is no, then the catheterization can lead to improved survival. Remember that this relates only to the issue of quantity of life and not quality of life. The decision-making process becomes more difficult when catheterization is looked at as a tool to decide whether angioplasty is an appropriate course of therapy. Unfortunately, there are little comparative data regarding angioplasty as an alternative to medical therapy. Coronary artery bypass surgery is the current standard of care for patients with three-vessel or left main disease, the only coronary anatomy that has been associated with improved survival after revascularization compared with medical therapy.1 Percutaneous transluminal coronary angioplasty,