Managing patients with the various manifestations of coronary heart disease keeps cardiologists busy, whether in out-patients, the cardiac catheter lab or the coronary care unit. There is no doubt that the specialty of cardiology has benefited from drug regulation imposed and supervised by the Food and Drugs Administration and the Medicines and Healthcare Products Regulatory Agency – commercial sponsorship may have funded and, to some extent driven, the use of the ‘gold-standard’ double-blind, placebo-controlled, multi-centre clinical trial to test potentially useful drugs, but at least the evidence base for clinical practice is well-founded as a result.
After hundreds of thousands of patient-years of phase III clinical trials and of post-marketing surveillance to establish what works and what doesn’t, the development of ‘patient care pathways’ and ‘best practice’ guidelines, clinicians may have thought they knew how to treat patients with angina. Nevertheless, patients are voicing their concerns over the impact of coronary heart disease on daily life and the inadequacy of their treatment, according to a survey conducted by Izzat and Knight and reported in this issue of the British Journal of Cardiology (pages 191–4). This patient survey is a reminder that clinicians’ expectations of delivering improved mortality and morbidity and relief of symptoms does not completely coincide with patients’ expectations of an improved quality of life and perfect symptom control.
It is not clear if compliance was poor or whether the patient population was representative of the generality of patients, but the survey suggests that many were very dissatisfied with the treatment of angina. The most common complaints were the adverse impact of angina and associated drug treatment on the quality of daily life (especially sex life); symptoms occurring at least once per week, despite most having had surgical intervention; the adverse effect of medication, especially beta blockers causing symptoms of tiredness, lethargy, nightmares and impotence; and beta blockers prescribed despite concomitant chronic obstructive pulmonary disease.
Both patients and doctors can learn from this study. Patients need to be better informed about the natural history of coronary heart disease and what can be done to try to alter it – that is control not cure. Patients also need to understand the limitations of pharmaceutical agents and what revascularisation strategies can realistically achieve in the short and long term. In particular, over-optimistic pre-operative expectations1 need to be tempered with a dose of reality – the TV soaps and tabloid newspapers and magazines may be partly responsible – but more detailed explanation prior to intervention would not go amiss.
Doctors, not unexpectedly, have a predominantly clinical and disease-oriented focus but, as this study confirms, they need to be aware that of greater importance to the patient is the limitation that illness (and its treatment) imposes on day-to-day life, leisure activities, work and on overall quality of life. Shifting the emphasis from a mainly clinical assessment of the severity of angina and control of symptoms as a marker of the effectiveness and outcome of medical and surgical interventions to a more comprehensive evaluation that includes an assessment of health-related quality of life would help.2
There is a range of validated tools, of which the Medical Outcomes Study Short Form 36 (SF-36),3 designed to assess the impact of disease on physical, mental and general health, function and well-being, has been extensively utilised in a wide range of chronic diseases and in many clinical trials. Even so, quality-of-life questionnaires are rarely incorporated into the routine of medical life, perhaps because they require time to complete. While a busy out-patient clinic may not be the place to interrogate patients in the necessary detail, postal surveys and self-administration of quality-of-life tools are proven and acceptable alternatives.4
Working doctors are a relatively healthy group and so few will have been the recipients of healthcare. Patient surveys at least afford the opportunity to view care from the patient perspective. This is particularly important at a time when the National Health Service (NHS) is increasingly protocol-driven, speed-orientated and process-focussed.
Conflict of interest
- Lindsay GM, Smith AN, Hanlon P, Wheatley DJ. Coronary artery disease patients’ perception of their health and expectations of benefit following coronary artery bypass grafting. J Advanced Nursing 2000;32:1412–21.
- Dempster M, Donnelly M. Measuring the health related quality of life of people with ischaemic heart disease. Heart 2000;83:641–4.
- Short Form 36. Available from: http://www.sf-36.org
- Seattle Angina Questionnaire. Available from: http://www.cvoutcomes.org