Evaluation of international guidelines: Recommendations for people with coronary heart disease

German disease management programs for people with coronary heart disease are essentially in line with recommendations made in international medical guidelines. Information could be added about nutritional advice, physical activity and counseling on smoking cessation, for example.

Coronary heart disease (CHD), sometimes also called coronary artery disease (CAD), is a chronic condition. It arises when the coronary arteries become narrow – those are the blood vessels around the heart that supply the heart muscle with oxygen. People who have CHD have hardened coronary arteries. This is known as arteriosclerosis. Arteriosclerosis can develop when fats and other substances in the blood accumulate at a damaged point within the blood vessel wall, and the vessel becomes increasingly narrow. Deposits like this (plaques) build up in the blood vessels of most people as they grow older. In advanced CHD, the narrowed coronary arteries may no longer be able to supply the heart with enough oxygen. This kind of blood supply deficiency is known as ischemia.

The main symptoms of coronary heart disease are sudden chest pains which can last anything between a few seconds and several minutes. The medical name for this is angina pectoris, which means "tight chest". Along with the pain, there is a characteristic feeling of tightness and anxiety. The pain may spread to the back of the neck, the back, arms or jaw.

Specialists differentiate between stable and unstable angina pectoris. In stable angina pectoris, symptoms usually only arise during or after physical exercise, like climbing stairs, and then disappear again. In unstable angina pectoris, which is much less common, symptoms already arise following very light physical activity or even when the person is resting. Unlike stable angina pectoris, it poses an immediate threat: the person is in danger of having a heart attack.

Heart attacks (myocardial infarctions) may be caused by coronary heart disease and can be acutely life-threatening. They occur when a coronary artery suddenly becomes so narrow that part of the heart muscle can no longer be supplied with oxygen. If it is not treated in time, part of the muscle tissue dies. Depending on the extent of damage, the heart muscle is permanently weakened, and the heart can no longer work properly. The likelihood of surviving a heart attack has greatly increased over the years: in countries like Germany, about 3 out of 4 people will survive a heart attack.

It is not clear exactly how many people have coronary heart disease in Germany. However, there are estimates of the number of people who have heart attacks: every year, about 1 to 2 out of 100 women between the ages of 25 and 74 have a heart attack. Men in the same age group have a slightly higher risk: about 4 out of every 100 men have a heart attack. However, the risk of CHD and possible complications can vary greatly from person to person. The main risk factors are believed to be age, gender, smoking, diabetes, being overweight and high blood pressure. Also, a lot of people who have CHD have high cholesterol levels. But there has not been enough research to say what influence high blood cholesterol levels alone may have.

CHD treatment aims to reduce the symptoms of angina pectoris, as well as to prevent heart failure (cardiac insufficiency) and heart attacks. Typical strategies include dietary changes, doing more exercise and giving up smoking. This is usually accompanied by medication. If the condition is serious, doctors often try to widen the coronary arteries.

Structured disease management programmes

Since 2002, people in Germany with CHD have had the option of joining disease management programs (DMP) offered by statutory health insurance funds. DMPs, or structured treatment programs, aim to ensure that people with certain chronic diseases get the best treatment possible. Interventions for achieving this include regular doctor's appointments, individual treatment plans and patient education courses. You can read more about DMPs in our feature on disease management.

Doctors who participate in a DMP have to follow certain quality criteria and defined treatment plans when treating their patients. In Germany, the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) determines what requirements a disease management program has to fulfill and what medical treatments it should include. The Federal Joint Committee is the national decision-making body of the self-governing body of doctors, dentists, psychotherapists, hospitals and health insurance funds. One important requirement is that the treatment offered complies with an evidence-based guideline. Guidelines are a kind of decision aid for doctors and patients. They aim to ensure that patients have the best possible quality-assured treatment. "Evidence-based" means that the guidelines are based on the results of reliable scientific studies, particularly randomized controlled trials.

Analysis of clinical guidelines

Medical knowledge is constantly growing, so recommendations for DMPs have to be regularly updated. For this reason, the Federal Joint Committee commissioned the German Institute for Quality and Efficiency in Health Care (IQWiG) in 2006 for the first time to compare the requirements of the coronary heart disease DMP with current international guidelines, and to point out any changes that may be needed. To do this, IQWiG researchers, together with researchers from the Technische Universität Berlin systematically assessed 21 clinical guidelines from different countries.

In its 2008 report, IQWiG found that the requirements for the German coronary heart disease DMP were generally in line with the current recommendations of German and international guidelines. The IQWiG researchers also concluded, however, that changes might be necessary for, among others, the topics of smoking, weight reduction and flu vaccinations. The specifications for treatments using certain medications and surgical procedures were also thought to need amending. The Federal Joint Committee took these results into account when they discussed updating the requirements of the coronary heart disease DMP.

Update of requirements and medical contents

In 2010 IQWiG searched again for current guidelines to be used for another reworking of the requirements for the coronary heart disease DMP in Germany. Guidelines that were already a part of the first report were not considered again. The IQWiG researchers see a need to add information about nutritional advice, physical activity and counseling on smoking cessation, based on the new search. In addition, other conditions such as hypertension and diabetes mellitus could be more fully considered and recommendations for flu vaccinations could also be included. There are also some aspects for several different medications that are not yet included in the DMP requirements. What is more, the guidelines recommend that those affected by this condition be instructed in education programs on how to recognize threatening situations and seek out medical assistance. One guideline recommends performing a cardiac catheterization under certain circumstances even when the coronary arteries are less constricted than what has been recommended so far. This recommendation is not found in the other guidelines that were evaluated.

In our topic area “Heart and circulation” you can read more about the research on cardiovascular diseases and find out what the signs of a heart attack are.


Author: Institute for Quality and Efficiency in Health Care (IQWiG)


Next planned update: February 2014. You can find out more about how our health information is updated in our text "Informed Health Online: How our information is produced".



Note

This health information is a summary of a scientific report published by IQWiG. It is not an assessment of the right to have health care services reimbursed by statutory health insurance funds in Germany. By law, decisions about the reimbursement of diagnostic and therapeutic procedures can only be made by the German Federal Joint Committee (G-BA). The Federal Joint Committee takes IQWiG reports into consideration in its decision-making process. You can find information about the decisions of the German Federal Joint Committee on its English-language website, www.english.g-ba.de.

© IQWiG (Institute for Quality and Efficiency in Health Care)