Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting

Abstract Study Question: Is the treatment and prevention of stable symptomatic angina pectoris by primary care physicians in VA hospital clinics consistent with good medical practice? Methods: A cross-sectional analysis was conducted in 7038 veterans with self-reported coronary heart disease who completed the Seattle Angina Questionnaire (SAQ) and who had made a primary care visit to one of seven VA general internal medicine clinics between May 1997 and January 2000. The main outcome measures included the anginal frequency scale of the SAQ and receipt of prescriptions of appropriate dosing for antianginal medication in three classes (beta-blockers, calcium antagonists, and long-acting nitrates). Effective treatment was defined as a SAQ score of ≥70 representing angina or use of sublingual nitroglycerin ≤2 times per week. Results: Mean age was 66 years, 98% were male, and coded diagnosis included 74% with angina, 51% a previous MI, 45% previous coronary revascularization, 70% hypertension, 27% COPD, and 22% smokers. Seventy percent of the patients with angina by the SAQ were considered adequately treated. Of the 30% of patients with more frequent symptoms, 22% were receiving no antianginal medications and 33% were receiving only one class of antianginal medication. Of the patients with frequent angina who were prescribed medications, 18% were taking no medications at the recommended therapeutic dose and 50% were receiving only one class of antianginal medication at the recommended therapeutic dose. Using multivariate analysis, the presence of CHF, COPD, GERD, joint pains, a previous stroke, and post-traumatic stress disorder were associated with a lower likelihood of successful treatment of angina. There was no difference in treatment outcome by provider type (attending, fellow, resident, PA, NP, etc.). Conclusions: A substantial proportion of patients with frequent episodes of chronic stable angina appeared to be receiving an inadequate antianginal regimen in terms of number of agents and dosages in the VA hospital clinics. Perspective: The Seattle Anginal Questionnaire is a well validated tool for assessing therapeutic interventions in angina. It may not be an appropriate tool for assessing treatment appropriateness in patients without a clinical diagnosis of angina, and in whom concurrent diagnosis may be confused with angina. Nevertheless, it is refreshing that a healthcare system is willing to report the magnitude of undertreatment of cardiovascular symptoms. It would be interesting to assess the relationship between treatment of symptoms and appropriateness of treatment of coronary risk factors. MR