The Pitfalls of Relying Solely on Guidelines for Chronic Coronary Syndrome: A Warning for Cardiologists

Dasaad Mulijono^1,2,3*

¹Department of Cardiology, Bethsaida Hospital, Tangerang, Indonesia

²Indonesian College of Lifestyle Medicine, Indonesia

³Department of Cardiology, Faculty of Medicine, Prima University, Medan, Indonesia

^*Corresponding author: Prof. Dasaad Mulijono, Department of Cardiology, Bethsaida Hospital, Tangerang, Indonesia.

Received: 30 March 2025; Accepted: 10 April 2025; Published: 22 April 2025

1. Introduction

Guidelines serve as essential tools in medical practice, providing a standardized approach to diagnosing and treating diseases. However, rigid adherence to these guidelines, particularly in the context of CCS, can be detrimental. The current recommendations suggest that cardiac check-ups are necessary only when patients exhibit symptoms [1,2]. However, real-world data show that a significant number of patients suffer from heart attacks without any prior warning symptoms, and some tragically lose their lives [3-6]. This article aims to caution cardiologists against over-reliance on guidelines and underscores the potential legal repercussions of misdiagnosis when a doctor merely follows protocol.

2. The Danger of Asymptomatic Cases

The guidelines for CCS emphasize symptom-based screening, which often delays necessary intervention. Many patients experience sudden cardiac arrest or acute coronary events despite having no prior symptoms [7]. Silent ischemia, undiagnosed microvascular disease, and individual variations in symptom presentation contribute to the high incidence of sudden, unexpected heart attacks. By strictly following guidelines that prioritize symptomatic evaluation, cardiologists risk overlooking a large cohort of high-risk individuals.

3. A Call for More Proactive Screening

Instead of relying exclusively on symptoms, cardiologists should adopt a more proactive approach to screening, particularly for high-risk populations. Factors such as family history, stress levels, lifestyle habits, and subclinical atherosclerosis detected via advanced imaging [8] should warrant earlier cardiac evaluation. While guidelines provide a structured framework, clinical judgment must take precedence, incorporating personalized risk assessment strategies that extend beyond standardized recommendations.

4. Legal and Ethical Risks of Over-Reliance on Guidelines

When a misdiagnosis or failure to diagnose occurs, one common defence is that the physician "followed the guidelines." However, this argument may not hold up in court. Medical malpractice cases often hinge on whether the standard of care was met. If it can be demonstrated that a reasonable cardiologist, considering the patient’s risk factors, should have acted beyond the guideline recommendations, the defence of guideline adherence becomes weakened. Courts may view rigid adherence to guidelines as negligence if it disregards clinical judgment and best practices [9-17].

Moreover, guidelines themselves are subject to periodic updates based on emerging evidence. A guideline that is valid today may be deemed inadequate in the future. If a physician fails to apply broader clinical reasoning and an adverse event occurs, legal liability remains a significant concern.

5. Case study

A 50-year-old asymptomatic male presented to our hospital for a second opinion. He had an unhealthy lifestyle and multiple coronary risk factors. A prior cardiology evaluation had deemed coronary CT imaging unnecessary due to his lack of symptoms. However, contrary to his expectations, coronary CT angiography performed at our facility revealed significant stenosis in the left anterior descending (LAD) artery. Consequently, he underwent successful percutaneous coronary intervention (PCI) using a Drug-Coated Balloon (DCB) technique, with an uneventful post-procedural recovery. Had the patient subsequently suffered a myocardial infarction following his initial consultation, concerns regarding potential misdiagnosis or delayed detection of critical coronary artery disease could have been raised.

6. Conclusion

While guidelines provide valuable direction in managing chronic coronary syndrome, they should not be followed blindly. Cardiologists must recognize the limitations of symptom-based screening and adopt a more comprehensive approach to assessing cardiovascular risk. Ignoring asymptomatic but high-risk patients can lead to fatal consequences and potential legal challenges. The key to optimal patient care lies in blending guideline-based practice with individualized clinical judgment, ensuring that life-threatening cardiac events are prevented whenever possible.

Author Contributions: D.M: Conceptualization, writing, review, and editing.

Funding: This research received no external funding.

Institutional Review Board Statement: Not applicable.

Informed Consent Statement: Not applicable.

Data Availability Statement: Data are contained within the article.

Conflict of Interest: The authors declare no conflict of interest.

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