First Word: The Gray Zones

In an ideal healthcare setting, all clinical decisions would be supported by well-designed, randomized trials, which provide an unequivocal pathway for every patient. However, how should physicians act when these data are not available?  

During this year’s Society for Cardiac Angiography and Interventions (SCAI) conference in Baltimore, Cardiovascular Business hosted a roundtable discussion, in which five interventional cardiologists discussed the best method of optimizing PCI outcomes. In that discussion, David R. Holmes, MD, and Mark A. Turco, MD, touched upon those patients who fall into the “gray zones of medicine,” where there are no guidelines, protocols or appropriate use criteria to guide care decisions. This is the point of clinical decision making when, according to the roundtable participants, good clinical judgment and experience become tremendously important.   

While some physicians are hesitant to recommend therapies for less certain patient populations, others depend on therapies that they have utilized with effective outcomes in their practices, in lieu of more concrete evidence.

Several such debates unfold in the pages of this issue. In our cover story, Rita F. Redberg, MD, and Matthew J. Budoff, MD, take opposing views on how to assess patients at intermediate- or low-risk of a future heart attack. In Redberg’s opinion, there are “no known benefits” of employing calcium scoring in this situation. However, Budoff staunchly defends the use of CT CAC screening for these lower risk patients, particularly due to the unreliable nature of the Framingham Risk Score in this population.

Physicians also discuss the need for clinical judgment for other medical gray zones. The RIVAL trial is the first large, randomized study to assess the transradial versus the femoral approach for PCI, and unfortunately, the results may have resulted in more questions than answers for interventionalists. Likewise, there are a slew of opinions about when and in which patients to employ vascular closure devices during cardiac catheterizations.

While there is a great deal of pressure on physicians to rely on the most up-to-date medical literature for decision making, the reality is: some data are still lacking, so clinical judgment remains an integral part of daily clinical practice.