Your Primary Care Team Can Manage Stable Heart Artery Disease without A Cardiology Referral
Many communities and primary care groups are far removed from big medical centers with catheterization labs and interventional cardiologists. That is no longer an obstacle to best practice care for patients with stable heart artery disease. A single primary care provider or nurse practitioner in your group can lead a team using a population health tool and protocols to manage these patients.
If a patient has chest pain that repeatedly occurs with the same level of exertion and is relieved by rest, he has stable chest pain. Angina is a historical diagnosis. He has a high probability of heart artery disease and should begin optimal medical therapy (OMT). A woman with repeated chest pain relieved by nitroglycerin over the age of 50 or who has cardiovascular risk factors like diabetes or smoking, also has a high probability or heart disease and needs OMT. It is the intermediate probability patients that are a problem.
If a patient has chest pain that is worse with movement, a deep breath, or pressing on the junction of rib and breastbone, that pain is more likely not heart related. It is coming from bones, tendons, ligaments, or cartilage. They don’t need OMT. It is the patients with intermediate risk that are the problem. Those are the ones where additional testing is appropriate.
None of this reflects usual care in the United State. If there is a suspicion of heart artery disease you will get a cath and if there is a blockage you will many times receive a heart artery stent even though we know that a stent adds nothing to OMT alone. OMT is the best treatment for these patients. A heart catheterization is an invasive procedure and it is not entirely without risk. Fully 2% of patients who have a heart cath experience “a major procedure-related complication.”
CT angiography is much more widely available than heart catheterization technology, and a primary care provider can order it. It is an non-invasive, accurate, safer, diagnostic strategy that can be used instead of stress testing and catheterization. Over three and a half years, there was no difference in the number of individuals who died or had a heart attack whether they had a diagnostic CT angiogram or heart catheterization. The estimated cost of a CT angiogram nationally is $850. The cost of a heart catheterization is ten times that. That does not count the preliminary cost of cardiology consultation, stress testing etc.
In Great Britain, people live longer for half the financial impact on gross domestic product. That is because they follow the evidence. If they are not sure if a patient has heart artery disease, they use CT angiography as the definitive test. Once the diagnosis of heart artery disease is established, primary care manages the patient and they provide optimal medical therapy. We can do that here.
If a patient has known heart artery disease, they can be managed by primary care as long as they are stable. If they are not known to have heart artery disease, a CT angiogram of the heart is an excellent way to establish the diagnosis and the need for OMT. That is not what we are doing now in our country. We cannot continue to do the same things and expect better health at lower cost.