Call for measures to counter under-diagnosis of angina

There is a glaring need for better objective guidance for GPs in the diagnosis and management of chest pain, according to a multi-disciplinary working group of the Angina Forum. The group agreed that a worrying over-dependence on subjective judgment by GPs in identifying suspected angina patients means that many cases may go undiagnosed.

Approximately 3% of adults in the UK are afflicted by angina, and about 330,000 new cases are diagnosed each year costing the NHS some £700 million per year. The Angina Forum’s consensus statement comes amid rising concern about angina following the publication in the British Medical Journal of new data showing a dramatic rise in the number of angina cases – a situation which exists in spite of a reduction in heart attacks.

However, the Forum points out that under-diagnosis, compounded by low public awareness, is a major problem and the true numbers of angina patients may be much greater. Professor Adam Timmis, Consultant Cardiologist at the London Chest Hospital commented: ‘There is probably an iceberg effect – the cases we see are just the tip of the problem.’

Illustrating the problem, Dr George Kassianos, a GP with specialist interest in coronary heart disease, cited the case of a patient presenting with atypical chest pain not linked to specific activity or trigger factors who was not referred but later turned out to have serious coronary heart disease. While this is anecdotal, Dr Kassianos pointed out that best practice is inevitably patchy in primary care and such cases were probably common.

‘Cases like this emphasise the importance of diagnostic guidelines for angina for GPs, which do not currently exist,’ he said. He also referred to an informal survey of 20 GPs which revealed that while all respondents were aware of primary care hypertension guidelines, none was aware of any similar guidelines for angina.

According to the National Service Framework for Coronary Heart Disease, patients with suspected angina should be referred to a Rapid Access Chest Pain Clinic (RACPC) and assessed within a maximum of two weeks. The new General Medical Services contract also rewards GPs for ensuring that ‘newly diagnosed angina patients’ are referred for specialist assessment.

But this places a clear onus on GPs to make appropriate diagnoses and decisions on who to refer, and in the absence of objective guidance too much depends on the GP’s clinical experience, according to the Forum members.

‘The new GMS contract puts the GP at the centre of management but there is probably insufficient objectivity at present,’ commented Norman Evans, Chief Pharmacist for Wandsworth PCT.

A further problem identified by the Angina Forum is that patients whose chest pain is assessed as low-risk by a RACPC are then returned to their GPs often with no clear indication of how they should be managed or what should be done if their condition deteriorates.

‘Ideally, there would be better communication from the hospital back to general practice and a management plan following discharge back to primary care,’ observed Dr Hugh McIntyre, Consultant Physician at the Conquest Hospital, Hastings and Honorary Consultant Cardiologist, Brompton Hospital, London.

The Angina Forum, a multidisciplinary expert group brought together to explore, research and communicate solutions to improved angina management, has previously highlighted the problems of patchy and inadequate medical management and the limitations of current therapeutic options.