Family Practice Advance Access originally published online on January 7, 2005
Family Practice 2005 22(1):43-50; doi:10.1093/fampra/cmh711
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Highlighting the need for better patient care in stable angina: results of the international Angina Treatment Patterns (ATP) Survey in 7074 patients
Department of Primary Care and General Practice, Primary Care and Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
Email: joeastaugh{at}blueyonder.co.uk
Received 28 September 2004; Accepted 12 October 2004.
Eastaugh JL, Calvert MJ and Freemantle N. Highlighting the need for better patient care in stable angina: results of the international Angina Treatment Patterns (ATP) Survey in 7074 patients. Family Practice 2005; 22: 43–50.
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Abstract |
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Background. Stable angina is a growing problem worldwide. Diagnostic methods and treatment regimens are established but data on actual practice are sparse and pre-date current guidance.
Objectives. To compare diagnosis and treatment information with guideline recommendations, and to assess impact on quality of life.
Methods. This international epidemiological survey recruited patients through primary and secondary care clinicians from China, Czech Republic, Greece, Hungary, Portugal, Russia and Slovak Republic. Participants experienced at least one episode of stable angina within the previous four weeks. Outcomes included use of diagnostic techniques, pharmacological treatments, surgical intervention, secondary prevention and quality of life.
Results. The study included 7074 patients, average age 63.3 (sd 10.3). Diagnosis of angina was most frequently as a result of chest pains (87.4%) with confirmaton by resting ECG in only 54.9%. Advice regarding risk factors was frequently given although secondary prevention was often ineffective with 41% of treated hypertensives lacking effective control. 97% of patients were taking at least one of the primary therapies for stable angina recommended by the guidelines with rates of individual therapies varying greatly across countries. Quality of life was lowest in countries with low rates of surgical intervention and poor observance of guidelines on pharmaceutical therapy.
Conclusion. Results show that the management of patients with stable angina does not meet recommended standards, although the appropriateness of these guidelines in poorer countries needs further investigation. Overall, the survey indicates that improved medical care and risk factor management would enhance prognosis and improve quality of life.
Keywords. Stable angina, epidemiological survey, quality of life.
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Introduction |
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Stable angina is a chronic condition that currently affects 2 million people in UK1 alone, and this number is set to increase in the future.2 The major cause of stable angina is coronary heart disease (CHD), which leads to an elevated risk of serious morbid events such as myocardial infarction (MI) and other cardiovascular related mortality.
The choice of treatment for people suffering from stable angina depends on the severity of the condition, pre-existing co-morbidities, individual response and tolerance to medication.3,4 In the UK clinical management is often undertaken in the primary care setting whilst in other European countries patients may have direct access to a cardiologist. Established management strategies take the form of lifestyle advice, pharmacological treatment5–7 and invasive therapies,8 which have been shown to reduce symptoms and, in the case of beta-blockers, prevent cardiovascular events.9 The role of CHD in the development of angina means that secondary prevention is often an important aspect of the management of these patients through anti-coagulant and statin therapy,10,11 however, reduction of symptoms is the main aim of treatment and this can be assessed through measurement of quality of life (QoL).
Observational studies of angina patients are sparse and those that do exist pre-date publication of relevant guidelines.12,13 The European Society of Cardiology has carried out a prospective observational study involving 24 countries as part of the Euro Heart Survey program but these data have yet to be reported. Consequently there is relatively sparse information available on the actual utilisation of currently recommended diagnostic strategies and treatment regimens, and the impact on QoL for people with this condition. The Angina Treatment Patterns (ATP) survey was undertaken with the aim of contributing to the knowledge base and appraising clinical practice to provide information from a variety of countries. In this paper we describe the principal results of the survey, comparing and contrasting observed data between countries and with established guidelines.
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Methods |
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The participating countries were China, the Czech Republic, Greece, Hungary, Portugal, Russia and the Slovak Republic. Inclusion relied upon participation of a national co-ordinator, and data collection centres were distributed across each country in rural and urban areas. The number of centres by district was proportional to the population in each district. Both primary and secondary care clinicians contributed to the survey on the basis of willingness to co-operate, interest and availability of patients. Inclusion criterion for patients was defined as at least one episode of stable angina within the previous four weeks. Data collection utilized a standardized clinical report form completed by the participating clinician, and took place over a four week period between April 2001 and November 2002. Paper records were returned to the Department of Primary Care and General Practice, The University of Birmingham, UK, for data entry. All data were stored under the provisions of the United Kingdom Data Protection Act and a random sample of 10% was dual data entered for quality assurance purposes. All analyses were performed using SAS V8.2 (SAS Institute, Cary NC).
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Results |
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The number of patients included from each country is shown in Table 1. By the end of the survey in April 2003 data were available for 7074 patients.
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Demography and risk factors
The proportion of patients below the age of 60 suffering from stable angina was highest in Russia (47.8%) and ranged to roughly a quarter of those surveyed in the Czech Republic, which also had the highest average age of participants (Table 1).
Countries differed with regards to who was responsible for patient management (Table 1). No patients in Hungary or Portugal were managed by a cardiologist in contrast to Chinese patients who were nearly all managed by a specialist. The Czech Republic, Hungary and the Slovak Republic reported that over 80% of patients were under the care of internists.
Nearly half of the patients recorded a family history of premature cardiovascular disease (Table 1) with Russia quoting almost double the rate of China (58.6% versus 31.9%, respectively). Russia also had the highest individual rate of prior MI (52.1%, Table 1), whilst for China and Portugal rates were considerably lower (18.7% and 15.5%, respectively). This was recorded as the basis of the initial diagnosis of CHD in 32.2% of patients.
Levels of obesity were similar for the European countries (25–35%) but much lower for China (3%). Doctors reported giving dietary advice to 88.3% of patients and percentages were comparable across countries (Table 2). Diabetes mellitus was also less frequent in China (19.6%) and hypertension was common across countries but most frequently cited in Russian patients (81.2%).
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Rates of smoking varied greatly: China had the highest rate of nearly one third and the Czech and Slovak Republics reported rates of less than 10% (self-reported). Doctors consistently advised patients with regard to their smoking habits (Table 2). The use of a formal rehabilitation programme was more common in China than in any of the European countries with rates of 67.8% compared to only 25.5% in the highest of the remaining countries (Greece) and dropping to 4.1% in Portugal.
Diagnosis
A complaint of chest pains most frequently contributed to the diagnostic process (87.4%) and 91.3% of patients had additional factors contributing to diagnosis. Overall, 52.2% of patients had an ECG exercise test but only around 30% of patients had coronary angiography although rates varied greatly between countries.
Overall nearly three quarters of patients had serum lipid profiles performed. Of these, 82.9% were found to have elevated total serum cholesterol. ESC guidelines were most widely consulted in Russia with 87.1% of cases reporting their use (Table 3). This signifies widespread use amongst different medical specialities as only half of the Russian patients were managed by a cardiologist (Table 1).
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Medical and invasive therapy
Data on therapeutic strategies for the patients surveyed are shown in Table 4. Treatment with beta-blockers, calcium channel blockers and nitrates alone or in dual combination is recommended therapy.3,4 In our survey treatment with each of these drugs in isolation were 542 (7.7%), 214 (3%) and 868 (12.3%), respectively. Dual therapy with any two of these three agents accounted for 3644 (51.5%) of the total population. Beta-blocker use alone is particularly low in China (2.4%) and the use of drugs from all three classes is higher (32.1%) than any of the other countries included in the survey. Patients who were managed by a cardiologist in any country were more likely to have attempted recommended therapy.
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Coronary therapies, which include nicorandil, trimetazidine and molsidomine, are newly emerging treatments. This survey indicates that Greece has the lowest uptake (13.3%) but in the Slovak Republic over half of patients reported consumption of at least one of these drugs.
The use of lipid lowering therapy varied greatly across countries. The highest proportion of current use was seen in Greece and the lowest in Russia, which had rates of 66.8% and 17.7%, respectively. Statins were the most widely used drug class for this purpose (74.1% of all lipid lowering drugs) over all countries. Lipid-lowering therapies were used or had been attempted in patients with elevated total serum cholesterol in 60.2% of cases. Russia showed the lowest use of this therapeutic strategy in patients where it was indicated with a rate of 31.3%.
The other commonly used therapy for secondary prevention is anti-thrombotics (including aspirin). Patients participating in the ATP survey showed high percentage use these drugs (89.2%) which were similar between countries.
Nearly two thirds of patients with a personal history of MI or hospitalization for acute coronary syndrome were taking an angiotensin converting enzyme inhibitor (ACEi) and 71% were taking a beta-blocker. Rates of ACEi use were consistent across countries but beta-blocker use varied widely, ranging from 42.9% in Portugal to 81.1% in Hungary. Similar trends between countries were seen in the 28% of patients with heart failure, with a total of 78.6% taking ACEi and 65.6% taking beta-blockers. Comparable results were seen in hypertensive patients.
Many of the patients surveyed had concomitant cardiovascular disease that may have been the original indication for some of the drugs classified as primary therapy for angina. Data shows that on average patients received 4.5 [standard deviation (SD) 1.6] cardiovascular drugs with primary therapy accounting for an average of 2.0 (SD 0.8).
In the ATP survey similar numbers of patients had PTCA and CABG (Table 4). The use of either type of surgical intervention was lowest in Russia, and Chinese patients were more likely to have PTCA rather than CABG (16.6% versus 1.8%). The use of stents as an adjunct to PTCA is a relatively new development and survey data shows that more of the recent PTCA procedures included stenting except in Russia and the Slovak Republic.
Quality of life
Quality of life was measured using a generic visual analogue scale (95% response) and the Canadian Cardiology Society Scale (CCSS)14 which is angina-specific (89% response, translated appropriately and completed by clinician). The mean health state scores (Table 5) were lowest in Russia and Hungary, the range over all the countries was 16 points with a mean score of 61.5 (SD 19.6). These scores did not vary between age groups divided according to age above or below 60 years.
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Of the four categories used in CCSS (Table 5) most patients stated that angina caused slight limitation of their ordinary activity (category II, 45.1%) although on an individual country basis, more of the Russian patients fell into the third category of ‘marked limitation of ordinary activity’ than in any of the other countries. Older patients were more likely to be categorised as III or IV—20.6% compared to 17.1% of those aged
60 (Table 5). Slightly more patients with co-morbidities fell into these two categories (20.7%) than those without (13.5%) and patients who had undergone invasive procedures experienced less limitation on daily activities than those who had not (difference of 4.4%). Greek and Portuguese patients reported the least number of anginal pains per week (2.4, SD 3.3 and 2.8, respectively, Table 5) and Russians exhibited the highest number with an average of 10.3 (SD 9.4). Mean GTN usage followed the same pattern as number of anginal pains across countries.
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Discussion |
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This survey represents the first extensive international effort to gather information covering risk factors, advice, diagnosis, treatment and QoL in patients with stable angina. The survey included countries in Eastern Europe as well as Southern Europe and China to provide information on patient characteristics, variation in management strategies and guideline compliance.
Diagnosis and risk management
Whilst personal history often accounts for diagnosis of stable angina, ESC4 and AHA/ACC3 guidelines state that confirmation should be sought through investigation. A minimum requirement is resting ECG and, where not prohibited, an exercise ECG and coronary angiogram should also be performed. Our results indicate that the actual numbers of patients undergoing these investigations falls short of this ideal.
Assessment and attenuation of risk factors is an important aspect of the management strategy. Relevant advice was frequently given by doctors but risk factors remained in a substantial proportion of patients. European countries do not appear to have well established rehabilitation programmes, which contrasts to their widespread use in China. It is not clear from the survey data whether the low numbers are due to a lack of availability or poor uptake by patients. These programmes may act as a valuable component of the management strategy, reinforcing doctors' advice although, from our data, there seems to be little difference in rates of smoking and regular exercise in Chinese patients compared with those from the other countries surveyed.
The relationship between elevated total serum cholesterol and increased risk of coronary events is widely accepted and lipid profiling is recommended universally in guidelines.3,4 In Greece only 57.5% of patients had this test performed and although its importance was recognized across the remaining countries, attainment of associated targets were often not achieved even when patients were receiving treatment. This was also true for hypertension and the fact that effective management of these important risk factors is neglected has adverse effects on prognosis for these patients. In the UK the New General Medical Services Contract for General Practitioners may offer a means of improving the management of risk factors. Targets for CHD patients cover lifestyle advice, requirements for blood pressure and total cholesterol measurements with attainment of targets. Evaluation of these measures on patient outcomes will be required to inform future strategy in this area for the UK and other countries.15
Pharmacological and invasive treatment
The data indicates that Portugal and China had low use of beta-blockers, which are recommended as first line therapy in AHA/ACC and ESC guidelines (in the absence of contra-indications), partly because of their favourable effect on prognosis post-MI and in patients with hypertension.16,17 This may be because, in both of these countries, rates of MI were considerably lower than for other countries. A surprisingly large number of patients in all countries received agents from all three of the major drug classes even though this is not recommended in any current guideline. Despite this high therapeutic burden average GTN use remains high and patients continue to be symptomatic, suggestive of sub-optimal dosing.
Drugs grouped as coronary therapies are thought to have cardioprotective effects that could reduce symptoms in stable angina.7 These drugs receive only a passing mention in ESC guidelines as evidence regarding their efficacy in angina treatment was not available at the time of development. Data from our survey shows that use of these agents vary greatly across countries, indicating the need for clear guidance in this area.
Invasive therapies are indicated when the patient is at high risk of death as a result of CHD or where medical therapies do not adequately control symptoms.3,4 Our data showed roughly equal use of each procedure except in China where PTCA procedures far outnumbered CABG. Evidence suggests that PTCA results in fewer morbid events but that patients are more likely to need pharmaceutical treatment and have higher rates of further re-vascularization. The latter may be attenuated by the use of stents4,18 which is becoming routine in some countries but not those with poor medical provision.
Quality of life
The standard angina mortality rate of 1.5–2%19 highlights that improvement of QoL is key for assessing management strategies in angina patients. QoL has been assessed in the ATP survey using a variety of measures and the consistency across each parameter indicates that these relatively simple tools are suitable for measuring to what degree treatment targets are being met. It is clear from the data collected that Russian patients are fairing poorly. The mean number of anginal pains per week is four times greater than the lowest of the other countries. The two countries with the lowest mean number of anginal pains per week and GTN use were Portugal and Greece, both have high rates of surgical intervention.
Hungary reported the lowest mean health state score and these patients had the lowest rate of optimal therapy in terms of dual or mono therapy. Patients in Russia generally have worse symptoms that are not managed optimally in accordance with guidance (either pharmacologically or surgically) despite having the highest proportion of patients managed by cardiologists within the European countries studied. This is due to the lack of availability of funding for medical treatment and equipment but demonstrates that in comparison to the more affluent countries where guideline methodology can be put into practice, patients suffer greatly in terms of both physical symptoms and quality of life.
Study limitations
The ATP survey provides much valuable information but interpretation of the data is not straightforward. The countries included in the survey have very different health care systems and there are obvious limitations in some countries regarding availability of services and funds for both diagnosis and treatment. However, the survey was designed to compare specific aspects of diagnosis, treatment and patient characteristics between countries so observing actual practice is valuable in terms of identifying where improvement in practice and additional resources are needed.
Our results demonstrate that in some of the Eastern European countries guideline use is low but we should also consider the appropriateness of guidelines developed for the wealthier Western European countries in these areas. WHO figures show that per capita health expenditure in Russia is less than a quarter of that in the UK.20 With this in mind the development local guidelines may be more suitable, taking into account differences in available resources and patient characteristics.
The QoL tools used have not been validated separately in each of the countries studied. Ideally this is necessary to draw firm conclusions from the results but the fact that countries in the survey with less optimal treatment and surgical intervention exhibit higher numbers of anginal attacks and lower QoL scores encourages us that the results represent a true indication of this outcome.
As with any survey that relies on voluntary participation by clinicians, those most interested in the topic are most likely to take part. These clinicians are consequently more likely to have good knowledge of diagnostic criteria, optimal therapy and dosing for this condition. Our results may therefore present a more positive picture of care than that actually received by the general population of people with stable angina in these countries.
Conclusions
The survey shows that management of patients with stable angina falls short of ESC7 and AHA/ACC6 recommendations. This is particularly true for risk management and secondary prevention such as attainment of target serum lipid levels and appropriate treatment of co-morbidities. Secondary prevention in the form of anti-thrombotics was widespread in all countries but our data indicate that patients who were managed by a cardiologist were more likely to receive optimal primary therapy. The relatively high use of nitrates and drugs from all three of these classes indicate that therapeutic management may not be optimal.
This survey provides valuable evidence that even within the more affluent countries studied there is scope for more effective management of patients with stable angina that would impact directly on the main treatment aims. Such improvements would not only improve prognosis but would also have an important positive impact on quality of life.
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Declaration |
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Funding: the study was sponsored by Servier. The sponsor was involved in the design and implementation of the study. Data analysis, interpretation, writing of the report and decision to publish were performed independently at the University of Birmingham, UK.
Ethical approval: Ethical approval was sought according to the regulations in each contributing country.
Conflict of interests: Nick Freemantle has received funding for research from commercial and non-commercial sources in the area of cardiovascular research. No other competing interests.
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Acknowledgments |
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The authors would like to acknowledge Werner Klein, who contributed so much throughout the project but sadly died before publication of this article.
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References |
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