From the Guidelines
If a patient refuses a monogram, the best alternative diagnostic test is a resting echocardiography, as it is recommended for the initial diagnostic management of patients with suspected coronary artery disease (CAD) and can help identify regional wall motion abnormalities suggestive of CAD, measure LVEF for risk-stratification purposes, and evaluate diastolic function. According to the 2019 ESC Guidelines on the management of chronic coronary syndromes 1, resting echocardiography and CMR are recommended in the initial diagnostic management of patients with suspected CAD. This recommendation is based on the importance of identifying alternative causes of angina, detecting regional wall motion abnormalities, and measuring LVEF for risk-stratification purposes.
Some key points to consider when choosing an alternative diagnostic test include:
- The patient's specific concerns about the monogram test
- Their risk factors for CAD
- The reason for screening
- The availability of local expertise and tests
- The clinical likelihood of CAD and other patient characteristics that influence test performance
Other alternative diagnostic tests that may be considered include:
- Chest X-ray, which is recommended for patients with an atypical presentation, signs and symptoms of heart failure, or suspicion of pulmonary disease 1
- Non-invasive functional imaging for myocardial ischemia or coronary CTA, which is recommended as the initial test for diagnosing CAD in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone 1
- Exercise ECG, which may be considered as an alternative test to rule-in or rule-out CAD when non-invasive imaging is not available 1
However, the most recent and highest quality study, the 2019 ESC Guidelines on the management of chronic coronary syndromes 1, recommends resting echocardiography as a key component of the initial diagnostic management of patients with suspected CAD.
In a different context, cardiac CT may be considered for diagnosis if the echocardiogram is not diagnostic and CMR imaging is unavailable, as stated in the 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy 1. However, this is not directly applicable to the current scenario, where the patient is suspected of having CAD.
Therefore, resting echocardiography is the recommended alternative diagnostic test if a patient refuses a monogram, based on the strongest and most recent evidence available 1.
From the Research
Diagnostic Tests for Patients Refusing a Monogram
If a patient refuses a monogram test, alternative diagnostic tests can be considered. The choice of test depends on the patient's condition and the suspected diagnosis.
- Understanding Patient Refusal: According to 2, treatment refusal is a common encounter in clinical practice, and it is essential to understand the underlying reasons for refusal. By discussing treatment options and assessing the patient's ability to make decisions, healthcare providers can achieve common goals that balance the best treatment strategies with the patient's best interests.
Alternative Diagnostic Tests
Several diagnostic tests can be used as alternatives to a monogram test. These include:
- Cardiac Magnetic Resonance Imaging (MRI): Studies have shown that cardiac MRI is a useful diagnostic tool for assessing suspected pulmonary arterial hypertension in patients with connective tissue disease 3. It has also been compared to stress echocardiography in the early evaluation of patients with intermediate-risk chest pain, with results indicating that cardiac MRI has higher sensitivity and may have improved performance characteristics 4.
- Stress Echocardiography: This test has been compared to stress cardiac MRI imaging in patients with intermediate-risk chest pain, with similar specificity, accuracy, and positive and negative predictive values 4.
- Myocardial Perfusion Imaging: A meta-analysis has shown that stress myocardial perfusion imaging using MRI, computed tomography, or positron emission tomography can accurately rule out hemodynamically significant coronary artery disease 5.
- Association Rule Mining: This technique can be used to extract hidden patterns and relationships between diagnosis and diagnostic test requirements, helping healthcare providers make informed decisions about which tests to order 6.
Considerations for Test Selection
When selecting an alternative diagnostic test, healthcare providers should consider the patient's condition, the suspected diagnosis, and the availability of testing options. By understanding the relationships between diagnosis and diagnostic test requirements, healthcare providers can make informed decisions and achieve efficient use of hospital resources 6.