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%). Patients presenting with acute coronary syndrome in SA are almost a decade younger than those in developed countries and in 2014, cardiovascular diseases caused 41000 deaths (46% of all-cause mortality) in SA. 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. 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. So, to achieve the outcomes reported by Hess et al. 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. Shared decision making may be able to elegantly resolve all these issues. However significant work is required before this can be effectively and safely applied to the general population of Saudi Arabia.
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Competing interests: No competing interests