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Atherosclerotic cardiovascular disease risk not associated with cardiology referral
Many primary care providers do not consider the cardiovascular disease risk for a patient who reports chest pain when deciding on a referral to a cardiologist, which may lead to over-referring, according to findings recently published in the Journal of Primary Care and Community Health.
“Having had patients walk into the door countless times complaining of chest pain, and seeing friends and colleagues send out to referral, we wanted to see if we were over-doing the referral. The general assumption was yes, we are. So rather than assume, we researched,” Jeffrey F. Scherrer, MD, of the department of family and community medicine at Saint Louis University School of Medicine in Missouri, said in an interview, in explaining what led to the study.
Scherrer and colleagues obtained electronic health record data from 170 patients treated at primary care clinics within academic institutions from 2008 to 2015 who were referred to a cardiologist. Patients were aged 40 to 79 years and had BMI data and LDL levels of less than 190 mg/dL on file, were classified as high or low risk for atherosclerotic cardiovascular disease and had no prior cardiologist referral on their record.
They found that 95 patients with chest pain were referred to cardiologist vs. 75 without chest pain (P < .0001). In addition, separate unadjusted models showed that chest pain (OR = 4.2; 95% CI, 3.07-5.73) and patients with high risk for atherosclerotic cardiovascular disease (OR = 1.41; 95% CI, 1.04-1.91) were associated with referral to cardiologist. After adjusting the data for atherosclerotic cardiovascular disease risk and confounders, chest pain was still significantly associated with referral (OR = 1.75; 95% CI 1.24-2.47).
“The biggest surprise was that family physicians are referring both low-risk patients with chest pain and high-risk patients with chest pain to cardiology at the same rate,” Scherrer told Healio Family Medicine. “You would think that low-risk patients wouldn't be referred, while the high-risk referral is appropriate. However, it is possible that patients request a referral based on their chest pain symptoms alone.”
He added that two-way discussions between doctors and patients, and medical tool utilization, may make referrals unnecessary in patients similar to the ones studied.
“There are many causes of chest pain. Without the appropriate symptoms or risk factors for heart attacks, it’s appropriate that primary care physicians have conversations with their patients talking about the different causes of chest pain. This might require physicians to gain further education and use proven risk calculators to appropriately categorize and evaluate chest pain in the primary care office.” – by Janel Miller
Disclosure: The authors report no relevant financial disclosures.
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This study by Buch, et al looked at a large cohort of patients in primary care who had chest pain as defined by their ICD-9 code, had referral to a cardiologist indicated by an EHR code and no prior history of cardiovascular disease. They found that a high American Heart Association/American College of Cardiology atherosclerotic cardiovascular disease risk score did not influence the primary care physician referral of chest pain patients to a cardiologist.
This finding is not surprising. The atherosclerotic cardiovascular disease risk calculator was designed to determine risk for myocardial infarction or stroke in asymptomatic patients; therefore, the determination of risk was not validated for patients with chest pain such as in this study.
Primary care physicians who assess patients with chest pain will generally take their atherosclerotic cardiovascular disease risk factors into consideration and recommend further testing to further evaluate cardiac etiology of chest pain. Although only about 8% of chest pain patients were referred to the cardiologist, about 73% had cardiac testing ordered by their PCPs. This suggests that PCPs are comfortable managing these patients by initiating the workup, rather than referring the patient out to a specialist regardless of the atherosclerotic cardiovascular disease risk score.
Buch, et al’s findings aside, PCPs need to keep an open mind when talking to patients about their chest pain symptoms regardless of the atherosclerotic cardiovascular disease risk score, as ischemic chest pain can occur in the absence of major cardiac risk factors particularly in younger women. Referral to a cardiologist is appropriate to provide reassurance to both the patient and PCP that persistent chest pain symptoms are fully evaluated.