Intended for healthcare professionals

Letters

Patients' physical disability may influence doctors' perceptions of suitability for risk assessment of CHD

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7219.1266a (Published 06 November 1999) Cite this as: BMJ 1999;319:1266
  1. Matthew Banks, clinical research fellow, department of cardiology (Mat{at}dirtyb.freeserve.co.uk),
  2. George Kitas, senior lecturer, department of rheumatology
  1. Dudley Group of Hospitals NHS Trust, Dudley, West Midlands DY8 5QX

    EDITOR—Gardener et al have raised the issue of barriers to referral in patients with angina, pointing to cultural gaps and perceptions leading to diagnostic confusion and inequality of referral for coronary revascularisation.1 Addressing this issue is essential for meeting the Health of the Nation target to reduce cardiovascular deaths.

    Patients' perceptions are only one of the factors that lead to referral barriers. Doctors' perceptions of patients' suitability can also have profound implications for referral patterns for risk assessment of coronary heart disease and subsequent revascularisation. For example, the presence of physical disability may result in doctors believing that risk assessment by exercise testing would be inappropriate or impossible. Thus a disabled patient may fall at the first referral hurdle.

    Rheumatoid arthritis is associated with increased cardiovascular mortality,2 the most likely cause of which is cardiovascular disease. We have systematically reviewed the records of 4000 consecutive patients who underwent coronary angiography over five years. On the basis of a prevalence of rheumatoid arthritis of 1-2%, we expected to find 40-80 patients who also had rheumatoid arthritis but in fact found only three. It seems that in everyday practice cardiovascular disease is not considered a condition worthy of investigation in patients with rheumatoid arthritis.

    We have assessed the presence of cardiovascular disease in 65 random patients attending the rheumatoid arthritis outpatients clinic (mean age 59 (range 40-70)). Forty six of these patients required a cane to walk long distances, while a further 13 used a wheelchair. None of them felt able to exercise fully, an essential requirement for adequate exercise testing.3 Despite this they were all successfully assessed for the presence of cardiovascular disease by adenosine-stressed myocardial perfusion imaging. Prevalent cardiovascular disease was 50%, half of which was prognostically high risk. The patients at highest risk were men with early onset and more aggressive rheumatoid arthritis.4

    Rheumatoid arthritis is only one example of conditions characterised by both increased risk of cardiovascular disease and physical disability Other examples include diabetic amputation, systemic lupus erythematosus, and peripheral vascular disease. Myocardial perfusion imaging may be an ideal non-invasive diagnostic and prognostic test for risk assessment of cardiovascular disease in disabled patients: it is highly sensitive and specific for the detection of cardiovascular disease and gives prognostic information superior to that given by exercise testing.5

    Physical disablement and doctors' perception of inability to perform exercise testing should not be a barrier to referral for diagnosis and risk assessment of cardiovascular disease.

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.