Some of the most practical and well-articulated clinical reasoning for ASCVD risk stratification and management I've read. Thank you for writing this up.
Thank you for sharing this story with us! Such a high-value piece as it does something rare in public-facing cardiology writing: it shows that an “abnormal stress test” is not a command, but it’s the start of a more careful conversation. What really stands out is your insistence on pattern over panic. Exertional symptoms matter. Stability matters. Exercise capacity matters. Anatomy matters. And once you lay those pieces together, the decision becomes much more adult than the usual reflexive “positive test = cath lab tomorrow”.
I also appreciate how clearly you translate the ISCHEMIA lesson. Too many people hear “no immediate survival benefit” and conclude either that stents are overused or that medical therapy is somehow passive. Your case shows the more honest middle: for stable patients, time exists for shared decision-making, medication optimization is a real treatment strategy, and the patient’s symptom trajectory often tells you when the invasive path becomes the right one.
And honestly, your colleagues’ responses were revealing in the best way. The pull toward intervention is not always about evidence alone; sometimes it’s about uncertainty tolerance for doctors and patients alike. Naming that makes the whole discussion more trustworthy.
Thank you for an excellent piece that translates an impactful study to a real world example—it’s invaluable to see this thinking spelled out in full for young trainees like myself
Thank you once again for a very informative piece. Not to be cynical, but I have a relative who works in a cath lab, which she said "makes the hospital the most money" of any department. I'm sure that never enters into the decision, right? Not to mention surgeons have an odd tendency to (almost) always recommend surgery. It's important for patients to know these things, especially when our PCP's don't even know what tests to order. Do you think AI might at least help them with that?
Wonderful post. As a Canadian practitioner, this is an outpatient clinical scenario that happens almost daily. I would say your approach, clinical reasoning, and application of trial evidence, should go into a teaching file for bread and butter cardiology for your NYU (I think) trainees.
So interesting that all your colleagues would go the invasive route off the hop….and do so based on THEIR OWN anxiety (and not even the patient’s own anxiety).
Honest question: quoting the study "The incidences of death from any cause and cardiovascular death were high and similar in the two groups (Figure 2A and Table 2)." Roughly 36% in either group. Is the medical intervention worth it either? Is there another path? Perhaps an extreme lifestyle change that promotes maximal metabolic health? I do understand that this is a cohort that, by design, had CKD.
The KETO-CTA trial, recently published (though I've heard they are planning to retract it based on some faulty data from the CLEERLY analysis), while it did not track MACE, did suggest that neither LDL-C nor ApoB were related to plaque progression. To be clear, the faulty CLEERLY data was at odds in the inverse direction with the rest of the data, which the authors want to clear up before they republish. I also understand that plaque progression is not the only indicator of future MACE.
The keto cta trial showed among the fastest plaque progression ever demonstrated. The subgroup that already had plaque progressed fastest. Would be absolutely unethical to recommend that diet to ischemia trial patients
Dr. Katz, I enjoy your writings and appreciated this piece. The discussion about how risk and informed consent resonated with me.
I have written an essay on my substack reflecting a CAD patient’s perspective on informed consent. I’m planning a follow-up looking more closely at the trials: ISCHEMIA, ASTEROID, and GLAGOV. I would also add (unpopular opinion) that a critical analysis is warranted, not just accepting the conclusions from these studies.
Some of the most practical and well-articulated clinical reasoning for ASCVD risk stratification and management I've read. Thank you for writing this up.
Thank you for the kind words and for reading
Thank you for sharing this story with us! Such a high-value piece as it does something rare in public-facing cardiology writing: it shows that an “abnormal stress test” is not a command, but it’s the start of a more careful conversation. What really stands out is your insistence on pattern over panic. Exertional symptoms matter. Stability matters. Exercise capacity matters. Anatomy matters. And once you lay those pieces together, the decision becomes much more adult than the usual reflexive “positive test = cath lab tomorrow”.
I also appreciate how clearly you translate the ISCHEMIA lesson. Too many people hear “no immediate survival benefit” and conclude either that stents are overused or that medical therapy is somehow passive. Your case shows the more honest middle: for stable patients, time exists for shared decision-making, medication optimization is a real treatment strategy, and the patient’s symptom trajectory often tells you when the invasive path becomes the right one.
And honestly, your colleagues’ responses were revealing in the best way. The pull toward intervention is not always about evidence alone; sometimes it’s about uncertainty tolerance for doctors and patients alike. Naming that makes the whole discussion more trustworthy.
Thank you for an excellent piece that translates an impactful study to a real world example—it’s invaluable to see this thinking spelled out in full for young trainees like myself
Much appreciate you reading
Great article. You are a wonderful writer who explains so clearly
Thank you!
This is excellent and will be sharing with my patients.
Very much appreciate that!
Love your articles and really appreciate your Substack.
Thank you once again for a very informative piece. Not to be cynical, but I have a relative who works in a cath lab, which she said "makes the hospital the most money" of any department. I'm sure that never enters into the decision, right? Not to mention surgeons have an odd tendency to (almost) always recommend surgery. It's important for patients to know these things, especially when our PCP's don't even know what tests to order. Do you think AI might at least help them with that?
AI in medicine has an evidence problem. For every single question, the answer is “maybe, but we have no data”
Wonderful post. As a Canadian practitioner, this is an outpatient clinical scenario that happens almost daily. I would say your approach, clinical reasoning, and application of trial evidence, should go into a teaching file for bread and butter cardiology for your NYU (I think) trainees.
So interesting that all your colleagues would go the invasive route off the hop….and do so based on THEIR OWN anxiety (and not even the patient’s own anxiety).
Honest question: quoting the study "The incidences of death from any cause and cardiovascular death were high and similar in the two groups (Figure 2A and Table 2)." Roughly 36% in either group. Is the medical intervention worth it either? Is there another path? Perhaps an extreme lifestyle change that promotes maximal metabolic health? I do understand that this is a cohort that, by design, had CKD.
The KETO-CTA trial, recently published (though I've heard they are planning to retract it based on some faulty data from the CLEERLY analysis), while it did not track MACE, did suggest that neither LDL-C nor ApoB were related to plaque progression. To be clear, the faulty CLEERLY data was at odds in the inverse direction with the rest of the data, which the authors want to clear up before they republish. I also understand that plaque progression is not the only indicator of future MACE.
The keto cta trial showed among the fastest plaque progression ever demonstrated. The subgroup that already had plaque progressed fastest. Would be absolutely unethical to recommend that diet to ischemia trial patients
Keep watching. Feldman, et al, are retracting the study based on false data from Cleerly. It's the false data that was showing the progression.
That group is making such a big deal about a tiny observational study over a short period of time.
It’s absurd. And if they are retracting their paper you should ignore all the data from it
Not serious people
Dr. Katz, I enjoy your writings and appreciated this piece. The discussion about how risk and informed consent resonated with me.
I have written an essay on my substack reflecting a CAD patient’s perspective on informed consent. I’m planning a follow-up looking more closely at the trials: ISCHEMIA, ASTEROID, and GLAGOV. I would also add (unpopular opinion) that a critical analysis is warranted, not just accepting the conclusions from these studies.
Thanks again for writing this.