Angina is underrecognized by cardiologists in clinic visits, compared with assessments made by the patients themselves, suggesting that a standard screening tool be used to improve accuracy.
Researchers conducted a survey of 1,257 patients and their 155 doctors at 25 cardiology outpatient practices in 19 states. All patients had documented coronary artery disease and completed the Seattle Angina Questionnaire (SAQ) before their office visits to assess angina symptoms and frequency. Right after they left, their cardiologists estimated and recorded their idea of how often their patients had heart pain and what their symptoms were.
Dr. Suzanne Arnold
Patient and physician estimates didn’t match: 411 patients (33%) reported at least one bout of angina in the previous month, but their physicians estimated a frequency of 14% (173 patients). Heart failure patients were more than three times as likely to have their angina underestimated, and patients who reported a single bout of angina per month were about 70% less likely than those who reported daily or weekly attacks.
Years in practice and the number of angina patients in the case load didn’t seem to make a difference. Patient demographics, atypical symptoms, and comorbidities besides heart failure didn’t either. “Some physicians were much better at recognizing the frequency of patients’ angina,” said lead investigator Suzanne Arnold, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and her associates.
“Evaluation of angina is subject to limitations inherent in history taking, including pre-existing biases and time constraints on the part of physicians and patients. ... Under-recognition of angina by physicians may result in under treatment with revascularization or medications that could improve patients’ quality of life,” and it wastes healthcare dollars, they said.
The team concluded that angina needs to be assessed directly from patients with a standardized survey like the Seattle Angina Questionnaire (SAQ). “We still routinely depend solely on an unstructured interview instead of directly asking patients using standardized assessments,” the investigators noted. “A more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease to appropriately guide further testing and treatment. ... The use of a validated, patient-centered tool for eliciting patients’ angina, such as the SAQ, should be tested in routine clinical care to see if it improves angina recognition, treatment, and outcomes,” the study team said (Circ Cardiovasc Qual Outcomes. 2016 AUG 16;doi: 10.1161/CIRCOUTCOMES.116.002781).
Patients in the study were, on average, 69 years old, and the majority were white men. About 40% reported previous myocardial infarctions, and more than half were stented. Well over three quarters were on beta-blockers for angina.
The senior investigator, John Spertus, MD, holds a copyright on the SAQ used in the study. Gilead Sciences funded the work. Investigators reported ties to Gilead, Abbvie, Genentech, Glumetrics, Maquet, Sanofi, AstraZeneca, Edwards Life Sciences, Roche, St. Jude Medical, Regeneron, Lilly, and ZS Pharma.