We congratulate Noonan et al1 for studying the appropriateness of coronary angiography at the Harvard Community Health Plan (HCHP) and for finding the proportion of coronary angiography procedures judged appropriate to be so high. We believe, just as Noonan and colleagues do, that increasing our knowledge about the validity of the appropriateness method is important.2 We note the strong but imperfect relationship between appropriateness ratings and coronary anatomy on angiography, and we did not expect, based on both the scientific literature and the clinical purpose of coronary angiography, to find a stronger relationship. In most cases, the appropriateness of coronary angiography is related to both the likelihood of anatomic disease and the utility of coronary revascularization should the expected anatomy be found. Thus, if a patient is unlikely to have life-threatening coronary artery anatomy, based on history, physical examination, and treadmill results, and has not had an optimal
Brook RH, Shekelle P. The Relationship Between Anatomic Disease and Appropriateness Ratings of Coronary Angiography. Arch Intern Med. 1996;156(5):584–587. doi:10.1001/archinte.1996.00440050144018
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