Abstract 1: Effect of Under-recognition on Angina Treatment in Stable Ischemic Heart Disease in Cardiology Outpatients: Seeing Eye to Eye is Key
Background: Clinical inertia in treating stable ischemic heart disease (SIHD), the phenomenon of not intensifying treatment, may occur more often when clinicians fail to accurately estimate patients’ symptoms. We hypothesized that under-recognition of angina would be associated with less treatment escalation in SIHD patients.
Methods: Cardiology outpatients with SIHD were recruited from a 25-site US registry and each completed the Seattle Angina Questionnaire (SAQ). Physicians independently quantified patients’ angina at end of visit, blinded to patients’ SAQ scores. Among patients who reported angina, under-recognition was defined as the physician reporting a lower frequency of angina than the patient. Based on providers’ management plan at end of visit, patients were divided into treatment escalation and no treatment escalation groups. Treatment escalation was defined as up-titration or addition of anti-anginal medication (beta-blockers, calcium channel blockers, nitrates, ranolazine), diagnostic/invasive testing or treatment (CT angiogram, stress test, cardiac catheterization, PCI, CABG), or hospital admission. Multivariable logistic regression model was used to examine the association of under-recognition with treatment escalation, independent of patient demographic and clinical characteristics, including the severity of angina.
Results: Of 1257 outpatients with SIHD, 411 reported angina of whom 178 (43.3%) were under-recognized by providers. Treatment escalation occurred in 106 (25.8%) patients with angina, of whom 28 (26.4%) were managed with medication up-titration, 67 (63.2%) with diagnostic/invasive testing and 11 (10.4%) with both. Patients with under-recognized angina were less likely to get treatment escalation (8.4% vs 34.1%, p=***), regardless if patients reported daily, weekly or monthly angina (Figure). In the multivariable model, under-recognition of angina remained strongly associated with a lack of treatment escalation (adjusted OR 0.13, 95% CI 0.07-0.24, p<0.001).
Conclusion: Under-recognition of patient’s angina in the outpatient setting is common and leads to markedly less frequent treatment escalation. Using validated tools to support clinicians’ recognition of patients’ angina should be considered to improve care and outcomes.
Author Disclosures: M. Qintar: None. J.A. Spertus: F. Ownership Interest; Significant; Ownership to the copyright of the Seattle Angina Questionnaire. K.L. Gosch: None. F. Kureshi: None. A. Shafiq: None. S.V. Arnold: None.
- © 2016 by American Heart Association, Inc.