br Discussion Nowadays the expected long term survival

Discussion Nowadays, the expected long-term survival of the vast majority of patients with CAD is excellent, with few recurrent cardiovascular events (Bauters et al., 2014a). During this prolonged period of outpatient care, diagnostic and therapeutic decisions by the referring cardiologist are major drivers of patient management. As highlighted above, recommendations based on high levels of evidence are often lacking for routine decisions relating to stable CAD outpatients. Although intentionally restricted in scope to ensure quick answers from participating physicians, the present survey nevertheless addresses several diagnostic and therapeutic issues that are extremely common for most cardiologists in everyday practice and for which the level of evidence is limited. Case #1 concerns the use of non-invasive stress tests in an asymptomatic post-MI patient. It is not currently known whether routine tests in this situation are beneficial, as no trial has assessed the impact of routine exercise testing on the clinical outcome of stable CAD patients. According to the European Guidelines (Montalescot et al., 2013), repetition of an exercise ECG in stable CAD patients may only be considered at least two years after the previous test (a class IIb level C-recommendation). According to the American Appropriate Use Criteria (Wolk et al., 2014), non-invasive stress tests in asymptomatic patients with known CAD are rated ‘rarely appropriate’ if performed <5years after CABG or <2years after PCI, and ‘may be appropriate’ ≥5years after CABG or ≥2years after PCI. Our results show that, despite these ‘neutral’ recommendations, the use of routine stress tests is a very firmly established practice among cardiologists. It is however noteworthy that variability exists with regard to this observation, and that about 15% of the physicians considered that routine stress testing is not useful as long as the patient remains asymptomatic. Beta adrenergic blocking agents can reduce or delay the onset of concentration equation pectoris and ST segment depression on exercise testing (Ho et al., 1985). We observed that about 2/3 of cardiologists would advise patients on β-blockers to discontinue this treatment prior to exercise testing. There are no clear guidelines on this question, and there would appear to be two different standpoints: (i) β-blockers should be stopped because this approach will maximize the ability of the test to detect ischemia; (ii) β-blockers can be maintained since there is no point in ‘detecting’ medically controlled ischemia in patients with documented CAD. Importantly, the approach based on practice of routine non-invasive stress tests cannot be separated from its consequences when the results are known. Although a normal test in this context is simple to manage and will be seen as reassuring by both patient and physician, it is important to determine the extent to which a test suggestive of ischemia is likely to impact on patient management. We intentionally chose a scenario in which exercise testing suggests ischemia without any markers of high-risk (preserved exercise capacity, moderate ST deviation, no angina during exercise), i.e., a situation where revascularization is unlikely to lead to improved event-free survival (Boden et al., 2007). In spite of this, our results show that a positive exercise test will almost inevitably lead to coronary angiography being performed, if ischemia is not ruled out by additional tests. Case #2 addresses a sequential approach to three different therapeutic and diagnostic decisions pertaining to the stable CAD patient. (i) Although there is no discussion about the fact that patients with systolic heart failure should receive a β-blocker (McMurray et al., 2012; Yancy et al., 2013), there is no evidence from randomized evaluations that β-blockers improve survival in the rest of the stable CAD population (excluding the early post-myocardial infarction period), and observational studies with propensity score adjustments have provided discordant results (Bangalore et al., 2012; Bauters et al., 2014b). Our data, showing that approximately 50% of the participating cardiologists would opt for a β-blocker in such patients, are thus concordant with the current literature. (ii) When atrial fibrillation develops in an otherwise stable CAD patient, it can prove difficult to find the best antithrombotic regimen with the most favorable risk-benefit ratio. International guidelines on atrial fibrillation have suggested that, in patients with stable vascular disease (i.e., >1year with no acute events), oral anticoagulation monotherapy may be considered (Camm et al., 2010; Fuster et al., 2011). It was however acknowledged that the level of evidence was low (class IIb level C-recommendation for both European and American guidelines) (Camm et al., 2010; Fuster et al., 2011), and data from recent registries have shown that in the real world, physicians are still reluctant to discontinue all antiplatelet therapy in CAD patients who need oral anticoagulation (Hamon et al., 2014; Lamberts et al., 2014). Again, the results of our survey show a balanced figure with 50% of cardiologists who would continue aspirin and 50% who would withdraw it (irrespective of the choice of anticoagulant). The fact that our fictitious patient had undergone DES implantation, even though it was over two years beforehand, may have affected the decision to pursue with aspirin. (iii) The last question relates to the management of recurrent angina in an elderly patient with a past history of PCI and CABG. Although a quarter of the cardiologists replied that pharmacological treatment would be their first-line choice, most physicians appeared to have a more invasive approach, and would recommend coronary angiography (either immediately, or once ischemia has been confirmed by a non-invasive test).