Physician-Level Variation in Under-recognition of Angina

Angina Under-recognized
Angina Under-recognized
Patients with heart failure or less-frequent angina were most likely to have their condition under-recognized.

Physicians at cardiology outpatient clinics diagnosed patients with coronary artery disease (CAD) who reported angina in the previous month with either less angina or no angina, according to results from the APPEAR (Angina Prevalence and Provider Evaluation of Angina Relief) study published in Circulation: Cardiovascular Quality and Outcomes.

“Angina is frequently under-recognized in routine clinical practice, and rates of under-recognition varied widely across physicians. Given the importance of assessing patient’s angina frequency to properly apply testing and treatment, these data support an assessment of angina directly from the patient,” wrote Suzanne V. Arnold, MD, MHA, of Saint Luke’s Mid America Heart Institute in Kansas City and colleagues. “By incorporating standard tools, such as SAQ-7 [Seattle Angina Questionnaire], as routine clinical assessments during office visits, a more consistent recognition of angina may occur.”

APPEAR was a cross-sectional, observational study designed to assess the frequency of angina and its impact on quality of life among outpatients with CAD. More than 150 cardiologists at 25 sites in 19 states participated in the study.

Before visiting the cardiologist, 411 patients with ischemic heart disease completed the SAQ—a self-administered, 19-item standardized assessment of angina burden during the previous 4 weeks. A score of 100 indicated no angina, while a score of 0-30 indicated daily angina.

Immediately after the visit, physicians were asked: “In the past 4 weeks, has the patient had chest pain, angina or angina-equivalent symptoms?” If they answered yes, physicians were then asked to characterize the patient’s chest pain, describe the frequency, location, associated symptoms, whether the symptoms were provoked by exertion or emotional stress, and if rest or short-acting nitrates relieved the symptoms.

Researchers found that physicians under-recognized angina in 42.1% of patients. Dr Arnold and colleagues wrote that under-recognized patients were:

  • more likely to have a diagnosis of chronic heart failure (26.0% vs 9.2%; P<.001)
  • more likely to have lower burdens of angina (monthly angina: 82.7% vs 72.3%; P=.01)
  • taking fewer antianginal medications (≥2 antianginal medications: 31.2% vs 45.8%; P=.002)

In a multivariable model, chronic heart failure (odds ratio [OR]:3.06; 95% confidence interval [CI]: 1.89-4.95) and monthly angina (OR:1.69; 95% CI: 1.12=2.56) were independently associated with a greater odds of under-recognition. Age, sex, race, socioeconomic status, and other comorbidities were not associated with under-recognition.

Researchers found “substantial variability” in under-recognition across physicians. Specifically, they observed that 15% of the variability in under-recognition could be attributed to physician-level variation (vs patient-level) as measured with the intraclass correlation coefficient. Among the 26 physicians who saw ≥5 patients who reported angina in the month before their office visit, the under-recognition ranged widely from 0% to 86%.

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Arnold SV, Grodzinsky A, Gosch KL, et al. Predictors of physician under-recognition of angina in outpatients with stable coronary artery disease. Circ Cardiovasc Qual Outcomes.2016;9. doi:10.1161/CIRCOUTCOMES.116.002781.