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Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial

BMJ 2016; 355 doi: (Published 05 December 2016) Cite this as: BMJ 2016;355:i6165

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Management of chest pain in Saudi Arabia: The relevance of shared decision making

Abdullah Almanea,1 Abdulaziz Alsaad,1 Rajkumar Rajendram2

1. College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2. Department of Internal Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

In Saudi Arabia (SA), 25% of adults have hypertension, 23.7% have diabetes and 35.5% are either obese or overweight.[1-3] It is therefore unsurprising that the prevalence of coronary artery disease is high (5.5%).[4] Patients presenting with acute coronary syndrome in SA are almost a decade younger than those in developed countries[4] and in 2014, cardiovascular diseases caused 41000 deaths (46% of all-cause mortality) in SA.[5] These horrific statistics mandate early detection of those at high risk; so patients presenting with chest pain in SA are generally managed aggressively.

We therefore read with great interest the study of shared decision making in patients with low risk chest pain reported by Hess et al.[6] Their model improved patient autonomy and increased patients’ understanding of their health. They delivered a personalized service tailored to the ideas, concerns and expectations of the patients; reducing decisional conflict whilst avoiding hospital admissions.

However the effective and safe use of such decision aids hinges upon the accurate risk stratification of patients. The Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Cardiac Events (GRACE) risk scores, for example, were developed from high risk populations and so are not as useful in lower risk populations in the emergency department.[7] So, to achieve the outcomes reported by Hess et al.[6] in our patients; an appropriate risk stratification tool must first be validated in the general population of SA.

Secondly, it is important to recognize that the majority of Saudi women, and even some men, routinely delegate the responsibility for decisions about their healthcare to a senior male relative. So not only must the accompanying decision aid be translated into Arabic it must also be adapted to reflect the cultural sensitivities of the local population.

The significant morbidity and mortality associated with cardiovascular diseases in SA provokes anxiety in both patients and healthcare professionals. Patient dissatisfaction is most commonly associated with unmet desire for further investigation and poor involvement in decision-making.[8-9] However, hospital admissions is one of the highest contributors to the total cost of treating ischemic heart disease in SA.[10] Shared decision making may be able to elegantly resolve all these issues.[6] However significant work is required before this can be effectively and safely applied to the general population of Saudi Arabia.


1. Al-Nozha MM, Abdullah M, Arafah MR, Khalil MZ, Khan NB, Al-Mazrou YY, Al-Maatouq MA, Al-Marzouki K, Al-Khadra A, Nouh MS, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A. Hypertension in Saudi Arabia. Saudi Med J. 2007;28:77-84.
2. Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, Khan NB, Al-Khadra A, Al-Marzouki K, Nouh MS, Abdullah M, Attas O, Al-Shahid MS, Al-Mobeireek A. Diabetes mellitus in Saudi Arabia. Saudi Med J. 2004;25:1603-10.
3. Al-Nozha MM, Al-Mazrou YY, Al-Maatouq MA, Arafah MR, Khalil MZ, Khan NB, Al-Marzouki K, Abdullah MA, Al-Khadra AH, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A, Nouh MS. Obesity in Saudi Arabia. Saudi Med J. 2005;26:824-9.
4. Alhabib KF, Hersi A, Alfaleh H, Alnemer K, Alsaif S, Taraben A, Kashour T, Bakheet A, Qarni AA, Soomro T, Malik A, Ahmed WH, Abuosa AM, Butt MA, Almurayeh MA, Zaidi AA, Hussein GA, Balghith MA, Abu-Ghazala T. Baseline characteristics, management practices, and in-hospital outcomes of patients with acute coronary syndromes: results of the Saudi project for assessment of coronary events (SPACE) registry. J Saudi Heart Assoc. 2011; 23: 233–239.
5. World Health Organisation. Saudi Arabia, Noncommunicable Diseases Country Profiles, 2014. World Health Organisation, 2014, Switzerland. Available at: (accessed 12/05/17).
6. Hess EP, Hollander JE, Schaffer JT, Kline JA, Torres CA, Diercks DB, Jones R, Owen KP, Meisel ZF, Demers M, Leblanc A, Shah ND, Inselman J, Herrin J, Castaneda-Guarderas A, Montori VM. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ 2016;355:i6165.
7. Yan AT1, Yan RT, Huynh T, Casanova A, Raimondo FE, Fitchett DH, Langer A, Goodman SG; Canadian Acute Coronary Syndrome Registry 2 Investigators. Understanding physicians' risk stratification of acute coronary syndromes: insights from the Canadian ACS 2 Registry. Arch Intern Med. 2009;169:372-8.
8. Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in patients presenting with physical complaints: frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med. 1997;157:1482–1488.
9. Abolfotouh MA, Al-Assiri MH, Alshahrani RT, Almutairi ZM, Hijazi RA, Alaskar AS. Predictors of patient satisfaction in an emergency care centre in central Saudi Arabia: a prospective study. Emerg Med J. 2017;34:27-33.
10. Osman AM, Alsultan MS, Al-Mutairi MA. The burden of ischemic heart disease at a major cardiac center in Central Saudi Arabia. Saudi Med J. 2011;32:1279-84.

Competing interests: No competing interests

15 May 2017
Rajkumar Rajendram
Consultant in Internal Medicine
Abdullah Almanea, Abdulaziz Alsaad, Rajkumar Rajendram
Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia