Physicians often under-recognize angina in patients with coronary artery disease

A multicenter, cross-sectional study found that physicians often did not recognize the frequency of angina in patients with coronary artery disease who were seen at cardiology outpatient practices.

Of the patients, 42 percent were believed by their physician to have less angina than they actually did.  There was a large variation of under-recognition among the physicians. The researchers defined under-recognition as the physician rating the patient’s angina at a lower frequency category than what the patient reported.

Lead researcher Suzanne V. Arnold, MD, MHA, of Saint Luke’s Mid America Heart Institute and the University of Missouri-Kansas, and colleagues published their results online in Circulation on Aug. 16.

The researchers mentioned that laboratory and imaging tests cannot measure angina, which is becoming more common and decreases patients’ quality of life. Thus, they noted that evaluating angina was subjective and prone to pre-existing biases and time constraints.

For this study, known as the APPEAR trial, they recruited 1,257 patients with coronary artery disease between April 2013 and July 2015 from 25 U.S. cardiology outpatient practices that participated in the PINNACLE quality improvement registry, which is sponsored by the American College of Cardiology National Cardiovascular Data Registry.

Before visiting with the cardiologist, patients completed the Seattle Angina Questionnaire (SAQ), a patient-reported, self-administered standardized questionnaire that measures five dimensions of health during the previous four weeks. After the visits, physicians were asked if their patients had chest pain, angina or angina-equivalent symptoms in the previous four weeks. If they answered yes, they were asked to describe the character of the chest pain, frequency, location, associated symptoms and whether the symptoms were provoked by exertion or emotional stress and relieved by rest or short-acting nitrates.

Of the patients, 32.6 percent reported having angina in the previous month. The mean age of patients with angina was 69 years old, while 60.3 percent were men, 91.4 percent were white and 14.1 percent were current smokers at their initial physician visit.

Of the patients with angina, 4.6 percent had daily angina, 18.7 percent had weekly angina and 76.6 percent had monthly angina. Most of the patients took one medication to reduce their angina. The most common medication was a beta-blocker.

The study also included 121 cardiologists, of which 83.5 percent were men. They practiced for a median of 18 years and saw a median of five patients who reported having angina.

Of the patients with angina, 42.1 percent were under-recognized by their physician. Patients whose angina was under-recognized were significantly more likely to have chronic heart failure and lower burdens of angina and receive fewer antianginal medications.

A multivariable analysis found that chronic heart failure and monthly angina were independently associated with greater odds of under-recognition by physicians. However, the patients’ age, sex, race, socioeconomic status and other comorbidities and the physicians’ sex and experience were not associated with under-recognition.

The researchers added that 15 percent of the variability in under-recognition could be attributed to physician-level variation.

They also mentioned the study had a few limitations, including that the results might not be generalizable to other cardiologists or physicians. In addition, they mentioned that they used a limited number of predictor variables, so they could have omitted important predictors of under-recognition.

Further, physicians knew they would be asked to estimate the patient’s chest pain after the clinic visit. Thus, the researchers said these findings likely underestimated the rates of under-recognition. They also could not determine if under-recognition of angina resulted in fewer tests or treatments for angina.

“These data underscore that a more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease,” the researchers wrote. “Because the physician’s assessment of angina is key in guiding further testing and treatment, under-recognition of the patient’s burden of angina could result in undertreatment. 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.”