Ambiguous Angina: Physicians’ Ability to Properly Identify Chest Pain Varies Widely

Accurately diagnosing angina can be a challenge for physicians, and many cases go under-recognized, according to the results of a new study. However, some clinicians are vastly better at quantifying chest pain than others.

“A unique feature of angina is that laboratory and imaging tests cannot measure it,” lead author Suzanne V. Arnold, MD (Saint Luke’s Mid America Heart Institute, Kansas City, MO), and colleagues write. Moreover, they say, failure to identify and treat it “could affect patients’ quality of life (by failing to intensify antianginal treatment) and increase costs to the healthcare system (because of increased hospital admissions).”

For their study of 1,257 coronary disease patients from 25 US cardiology outpatient practices taking part in the APPEAR study, the researchers matched up patient responses to the Seattle Angina Questionnaire (SAQ) and the independent diagnoses of their cardiologists after examination.

Of the 411 patients who reported symptoms in the previous 4 weeks, 42.1% were believed by physicians to have less angina or none at all. On multivariate analysis, patients with chronic heart failure (OR 3.06; 95% CI 1.89-4.95) and those with monthly versus daily/weekly symptoms (OR 1.69; 95% CI 1.12-2.56) were more likely to have their angina underrecognized. Notably, no other patient or physician characteristics were associated with underrecognition.

Also, the researchers saw substantial variation across physicians with regard to their ability to accurately diagnose angina—rates of underrecognition ranged from zero to 86% among the 26 physicians who evaluated at least 5 patients over the study period.

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

The findings were published online, August 16, 2016, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

‘Creative Implementation Strategies’ Needed

The discrepancy between how well doctors and patients identify angina is “likely related to modern practice associated with computer distractions, shortened face-to-face interview time with patients, as well as the nuanced interrelationship with the patient’s ability to provide a good history and the physician’s ability or willingness to obtain an accurate history,” John Erwin III, MD (Texas A&M College of Medicine/Baylor Scott & White Health, Temple, TX), commented to TCTMD in an email.

Additionally, training could play a role in a physician’s diagnosis accuracy, he said, but “compulsiveness, connection to the patient, and time spent with the patient,” also could be responsible.

“Despite the importance of assessing angina burden in patients with coronary disease,” Arnold and colleagues say, “we still routinely depend solely on an unstructured interview, instead of directly asking patients using standardized assessments.” Overcoming the barriers to using patient-reported outcomes in clinical care may require “creative implementation strategies . . . including novel mechanisms to collect, score, and interpret patient-reported outcomes data,” they suggest.

Erwin recommends physicians not only make better use of available tools and surveys but also spend more time with patients. Obtaining an accurate history is more important than the “ever-increasing focus on documentation,” he said. “The SAQ seems to be a well-validated tool, but every tool is only as good as the user and the system in which it is used.”

The researchers point out that the recently introduced shorter SAQ—consisting of only seven questions versus the original 19—could also prove useful.

Ultimately, Erwin observed, these findings “should cause doctors to reemphasize the importance of taking a good history to provide the best patient care.” Future studies should evaluate how “event rates, hospitalization, revascularization, and patient quality of life” are affected by improper angina recognition, he added.

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  • Arnold SV, Grodzinsky A, Gosch KL, et al. Predictors of physicians under-recognition of angina in outpatients with stable coronary artery disease. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.

  • APPEAR was supported by an investigator-initiated grant from Gilead Sciences.
  • Arnold and Erwin report no relevant conflicts of interest.

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