Effect of Angina Under-recognition on Treatment Escalation in Outpatients with Stable Ischemic Heart Disease
Abstract
Almost a third of outpatients with chronic coronary artery disease (CAD) report
having angina in the prior month, which is frequently under-recognized by their
cardiologists. Whether under-recognition is associated with less treatment escalation to
control angina, and potential underuse of treatment, is unknown.
Patients with CAD from 25 US cardiology outpatient practices completed the Seattle
Angina Questionnaire (SAQ) prior to their clinic visit, and angina was categorized as daily,
weekly, monthly and no angina. Cardiologists (n=155) independently quantified patients’
angina, blinded to patients’ SAQ scores. Under-recognition was defined as the physician
reporting a lower category of angina frequency than the patient. Among 1257 patients with
CAD, 411 reported angina in the past month, of whom 178 (43.3%) patients were under
recognized. Treatment escalation—defined as intensification (up-titration or addition) of
antianginal medications, referral for diagnostic testing or revascularization, or hospital
admission—occurred in 106 (25.8%) patients with angina. Patients with under-recognized
angina were less likely to get treatment escalation than patients whose angina was
appropriately recognized (8.4% vs 39.1%, P<0.001). In a multivariable logistic regression
model adjusting for demographic and clinical characteristics, as well as the burden of angina, under-recognition remained strongly associated with a lack of treatment escalation (adjusted
OR 0.10, 95% CI 0.04-0.21, P<0.001).
Under-recognition of angina in cardiology outpatient practices is associated with less
aggressive treatment escalation and may lead to poorer angina control. Standardizing clinical
recognition of angina using validated tools could reduce under-recognition of angina,
facilitate treatment, and potentially improve outcomes.
Table of Contents
Introduction -- Methodology -- Results -- Discussion -- Conclusions and future directions -- Appendix
Degree
M.S.