To help standardize care for one of the nation's leading medical conditions, three national groups teamed together last week to issue the first set of treatment guidelines for chronic chest pain.
Known as angina, the condition afflicts an estimated 10 million Americans and costs billions of dollars each year to treat, according to the American College of Cardiology. Yet many proven medical therapies for angina are dangerously underused and a handful of untested treatments are overused, according to the authors of the guidelines.
"What we want to do is to encourage the tests and treatment that are proven to be of benefit and to discourage the use of others that have not been proven," said Raymond J. Gibbons, vice chairman of the task force that drafted the guidelines, which were issued by the American College of Cardiology, the American Heart Association and the American College of Physicians.
Such scientifically proven therapies as prescribing daily aspirin and other anti-angina medication, controlling elevated blood cholesterol levels and high blood pressure and encouraging smoking cessation are "not applied anywhere near as uniformly as we would like," said Gibbons, who is senior staff cardiologist at the Mayo Clinic in Rochester, Minn. "This is an effort to try to increase the percentage of patients who receive good care."
Doing so could make a significant difference in survival rates. Taking a baby aspirin tablet daily can reduce an angina patient's risk of heart attack by as much as 25 percent, Gibbons noted. "We would be very pleased if we could do that," he said.
At the same time, the guidelines note that an increasing number of physicians routinely treat angina with popular but unproven therapies, including folic acid, vitamins C and E, as well as garlic supplements.
"Although there's been a wave of enthusiasm for vitamin E and vitamin C, the committee felt that current evidence does not support their use as routine therapy," Gibbons said. "We want to discourage the use of those things."
Angina is caused when arteries that supply blood to the heart become partially blocked with fatty plaque. As the plaque continues to accumulate, blood flow declines. This reduction often is not a problem when the heart is at rest, but upon exertion, heart cells are suddenly deprived of blood and oxygen, producing chest pain. Chest pain signals the death of heart cells, a process called ischemia. If enough cells die, a full-blown heart attack occurs.
Most people with angina seek treatment from their family physician or general internist, rather than a cardiologist. The guidelines are designed to standardize and streamline such care by providing extensive flow charts of symptoms and treatments.
"There are a zillion tests that you can do and the guidelines say, start here, if you find this, go to here, and that is very helpful," said Jennifer Daley, an internist at Massachusetts General Hospital in Boston who helped write the guidelines. "For the practicing internist, it is often very confusing to decide which test to use and how quickly."
The guidelines also suggest doctors use standard exercise treadmill tests first to detect possible blockages.
Newer, high-tech and more expensive diagnostic tests are increasingly ordered in place of the treadmill test. One of the most popular is the ultra-fast CT scan, also known as electron beam CT imaging. The guidelines suggest that this technology should be used sparingly.
"Multiple studies show the value and usefulness of standard exercise treadmill testing in people with chronic stable angina," Gibbons said. "It has a clear role, and there are few studies to demonstrate use of electron beam CT."
Still, some doctors feel strongly about such testing.
"I happen to be a believer in the ultra-fast CT," said David Pearle, director of the cardiac care unit at Georgetown University Hospital in Washington. "I think it is useful, but the question is how do we use it?"
Once a blockage has been diagnosed, the guidelines help doctors sort through the wide range of treatment options. Therapies are ranked in value according to the scientific evidence. "To quantify and show how strong the evidence is for these things is very useful for the practicing physician," Pearle said.
The 10 leading angina treatments are divided into a systematic approach that begins with diagnosis of the blockage and moves from there to standard medical treatment, including invasive methods to remove the blockages, such as angioplasty or coronary artery bypass surgery as needed.
According to the guidelines, treatment for most angina sufferers begins with A (aspirin and anti-anginal medication), jumps to B (prescription of beta blocker drugs to control high blood pressure where needed) and C (cholesterol-lowering drugs and giving up cigarettes). D includes a diet to control blood pressure, lose weight and lower blood cholesterol, along with diagnosing and controlling diabetes, a major risk factor for heart disease. Finally, step E urges doctors to educate their patients about heart disease and to encourage them to engage in regular exercise.
Many doctors said the guidelines are long overdue in setting standards of care. "Once you have established that the patient has blocked arteries and how big the blockages are, it gives you treatment strategies for reducing chest pain and treating the symptoms," Daley said. "But it also has a very nice road map to show how to reduce the risk factors for coronary artery disease."
Some doctors said the guidelines will provide needed ammunition to help dissuade patients from choosing popular, but unproven, treatments such as chelation therapy, which is designed to strip out calcium and metals from the blood.
"This report stomps down hard on chelation therapy and quite appropriately so," Pearle said. "Its use has become quite widespread."
Experts said there is also a downside to the guidelines. By establishing medical consensus on angina treatment, some worry that treatment will become too rigid.
"Usually when a set of treatment guidelines comes out, they are often obsolete in two to three years, but they still go on being quoted," Pearle said.
Another drawback is that the guidelines could be used as justification by health insurance companies to refuse to pay for some procedures.
"If I do something that is in an intermediate category, or choose to perform a cardiac catheterization for indications that are not completely clear, the reimbursement may be in jeopardy," Pearle said.
Authors of the guidelines say the trade-off is worthwhile because millions of people suffer from angina.
"We are certainly hoping that these guidelines will change practice patterns," Gibbons said. "If we can increase by only a few percentage points those patients who receive appropriate care, it will have a major impact.