Variation in patient utilities for outcomes of the management of chronic stable angina: implications for clinical practice guidelines

Patients with the same degree of chronic chest pain may differ in the amount of distress they experience. Researchers surveyed 211 patients with chronic stable chest pain to assess the amount of distress experienced by the patients. In each progressively severe disease class, the patients experienced increasing distress from their symptoms. Patients with less severe chest pain categorized in treatment classes I or II were bothered significantly less by their symptoms than patients with more severe chest pain in treatment classes III or IV. Within each treatment class, patients were bothered to varying degrees by their symptoms. There was approximately a 33% chance that patients in treatment class II would be bothered by their symptoms more than patients in treatment class III or IV. Clinical practice guidelines for chronic stable chest pain should be based on patient preferences instead of the severity of symptoms alone.
Objective. - Although practice guidelines sometimes make recommendations based on symptom severity, they rarely account for how patents feel about their symptoms. To investigate the possible importance of patent preferences in treatment of ischemic heart disease, we assessed attitudes toward symptoms in patients with angina pectoris. Design. - case series. Selling.- Ambulatory cardiology clinics at two tertiary care medical centers. Patients. - A total of 220 subjects were selected from 589 patients with chronic stable angina referred from cardiologists to achieve patent samples balanced for sex, race, and angina severity. Main Outcome Measures. - We measured patients' attitudes toward their angina using the rating scale, time trade-off, and standard gamble utility metrics. Reliability of measurements was evaluated by repeating the assessments 2 weeks later on 50 willing patients. Results. - While the mean responses followed the expected patterns (those with more severe Canadian Cardiovascular Society scores chose lower utilities), attitudes toward symptoms varied substantially among patients with similarly severe angina. For example, there was a 33% chance that a patient with class II angina had a time trade-off utility that was lower (ie, more bothered by symptoms) than a patient with more severe angina (class III/IV). This variation in utilities was not due to random error in the assessments. Conclusions. - Angina patients with similar functional limitation vary considerably in their tolerance for their symptoms, as measured by utilities. Our findings suggest that guidelines for the management of ischemic heart disease should be based on the preferences of the individual patient rather than on symptom severity alone.