Implications and Challenges Using Practice Guidelines for Chronic Angina

• Angina pectoris
• Practice guidelines
• Myocardial infarction
• Quality of health care
• Delivery of health care

Since 1980, the American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly produced guidelines for the management of cardiovascular diseases. There are now approximately 25 such guidelines that define acceptable approaches to diagnosis and management of patients with heart disease. These guidelines are intended to assist physicians in defining the optimal range of practices for most patients with a given condition. It is also recognized that the ultimate judgment in patient care rests with the individual physician weighing the circumstances for an individual patient. Nevertheless, guidelines have become increasingly important because significant gaps between public health goals and actual achievements in health care delivery have been identified (1, 2).

The Health Care Finance Administration (HCFA) tracks the quality of care provided to Medicare recipients. An initial report, published last year, addressed health care delivery across states by analyzing 24 measures (1). The percentage of patients receiving appropriate care ranged, on average, from a high of 95% to a low of 11%. Eight measures were examined for acute myocardial infarction, and two were examined for heart failure. All were based on ACC–AHA recommended guidelines, and most were class I recommendations (conditions for which there is evidence or general agreement that a given procedure or treatment is useful and effective). It is understood that all class I and class III recommendations (conditions for which there is evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful) can now serve to define the quality of care delivered on a state or hospital level.

Three guidelines have been published for patients with ischemic heart disease. They address chronic stable angina (3), unstable angina and myocardial infarction without ST-segment elevation (4), and …