Comparação da adequação das indicações de cinecoronariografias diagnósticas eletivas entre os sistemas de saúde público e privado no estado de Minas Gerais

Abstract

Background: By the year 2020, coronary artery disease will be the main cause of death in the world. In Brazil, cardiovascular disease accounted for 34% of all deaths reported in 1999 and coronary artery disease represented approximately half of cardiovascular deaths. Currently, coronary angiography is the standard procedure to diagnose coronary artery disease (CAD) and an important tool for clinical decision-making concerning patients with CAD. Due to the extensive use of coronary angiography, utilization rates for this particular procedure are increasingprogressively and thus the American College of Cardiology, the American Heart Association and the Brazilian Cardiology Society have established guidelines for cardiac catheterization and coronary angiography. Nevertheless, the extent to which these guidelines are being used in the Brazilian health care system is unknown. Aims: To evaluate the appropriateness of the criteria for the indication of electivecoronary angiography in CAD patients using the public and private health care system in Minas Gerais, Brazil. Methods: The study included male and female patients between the ages of 18 years old and who were serviced in the private and public health care system in Minas Gerais, Brazil. This study group had clinical indications for elective coronaryangiography. Demographic data such as sex, age, height, weight and profession; clinical data and particularly ischemic heart disease history; major coronary risk factors such as hypertension, smoking behavior, lipid disorder, diabetes and CAD family history; non-invasive cardiac test results (exercise stress test, rest and stress echocardiography and myocardial perfusion scintigraphy) were collected during patients hospital stay. Based on clinical data, patients were classified according to coronary angiography indications as having stable angina, nonspecific chest pain or asymptomatic. The clinical data and results of non-invasive cardiac tests were used with the results of coronary angiography in a blade fashion, so that they could fit the indications for the coronarygraphy as Class I, IIa, IIb or III, according to the guidelines established by the American College of Cardiology, American Heart Association and the Brazilian Cardiology Society. For the purpose of this study, the indications included in classes I and IIa were considered to be appropriate, thoseincluded in class IIb were considered uncertain, and finally those included in class III were defined as inappropriate. Significant coronary artery stenosis was defined as at least 50% lumen diameter narrowing of a major epicardial artery or its major branches. Statistical analysis was performed using Epi-Info 6.0 (CDC, Atlanta, GA) and Stata 7.0 (Stata Corporation, College Station, TX). Ethical issues: The research project was approved by the ethical committee from all institutions involved. Informed consent was obtained from all participants. Results: A total of 466 patients were included in the study, 321 (68,9%) from the public health system and 145 (31,1%) from the private system. Patients from the19 public health service were younger than patients in the private health system and females were predominant in the private system. Arterial hypertension (OR 2,39; CI 95% 1,49 to 3,82; p<0,01) and sedentary (OR 18,6; CI 95% 11,0 to 31,4; p<0,01) predominated in the public service. Stable angina and unspecific chest pain were detected more frequently in patients from the public health system. According to the AHA/ACC guidelines, 32.1% of patients from the public health system and 35.9%from the private health system were included in class I and IIa; 65.4% from the public service and 45.5 % from the private system were allocated in class IIb and 2.5% and 18.6% of patients from the public and private system were included in class III respectively. Sixty percent of patients did not show significant coronary artery stenosis and in both health care systems only a few number of non-invasive cardiac test to diagnose coronary artery disease were observed. Conclusions: Coronarygraphy utilization rates were found to be highly uncertain orinappropriate as demonstrated by the high prevalence of patients allocated in class IIb and III and the high prevalence of normal coronarygraphy. Non-invasive tests were performed in the minority of cases. Our study shows that both health care systems are not following the guidelines for elective coronarygraphy.