Determination of Characteristics of Patients with Functional Coronary Artery Disease and How They Differ From Those with Atherosclerotic Disease
Summary
The purpose of this fellowship was to provide an opportunity to gain an increased understanding of patients with functional coronary artery disease (CAD) through the conduct of research. I am a nurse practitioner at Southlake Regional Health Centre (SRHC) in the Cardiovascular Integrated Physiology Program (CVIP). I care for a patient population who historically have been underdiagnosed and undertreated. Patients with functional CAD (Syndrome X, Syndrome Y, vasospasm, etc) are oftentimes provided inappropriate reassurance that their symptoms are not cardiac in origin, however there is data that refutes this belief and actually has shown that this population is at risk for adverse events. CVIP is a research affiliated program dedicated to the assessment, diagnosis and management of patients with functional CAD. Patients who are seen in CVIP consent to allowing the program to collect and analyze their personal health information for research purposes. The fellowship provided an opportunity for myself to collect, organize and analyze the data that is gathered in CVIP for the purpose of gaining increased insight into the clinical characteristics of patients with functional CAD and provide an understanding into the development of the disease process. The initial goal was to compare and contrast patients with suspected functional CAD to those with known epicardial CAD to determine any significant differences between the two populations. This began first with a review of the literature in order to summarize current research to date. From here, research questions were created and ideas generated which guided further ideas for analysis. Data collection, research database management, and data analysis were all areas that I wanted to develop. Once data analysis was complete the results were presented to the interprofessional team members with the intention to improve knowledge translation with the overall goal to improve patient care to this population.
The overall learning goal for this fellowship was to increase my knowledge base of the patient population which I care for in CVIP and to disseminate this knowledge to other members of the health care team with the intention to improve patient care. The second goal I wanted to achieve was to develop skills in the research process from the development of a research question, data collection, database management, and data analysis and interpretation. Having protected time to develop these skills has given me the opportunity to immerse myself in this underserved population. In my graduate degree I developed novice skills in the research process but never had the opportunity to put these skills to use in my clinical practice. I was able to reawaken my skills in literature review and critically appraise the current literature on functional CAD which gave me a solid background of what is currently known about this condition. I had never been involved in managing my own research database so this was completely foreign to me. With the guidance of mentors I developed the basic knowledge and skills required to specifically organize data in a manner that allowed for data analysis. Through studies and mentorship I learned how to perform appropriate statistical analysis on categorical and continuous variables by performing Chi Square, T-tests, means and standard deviations. Some hiccups along the way taught me the importance of ensuring that the database is as accurate as possible in order to trust the results. This drove home the importance of always looking at data through a critical lens.
As the analysis was taking place, new ideas developed which provided me the opportunity to explore other research questions and gave me more information on the referral patterns to CVIP. This was an interesting finding and provides insight into potential bias in the beliefs of the disease process in the eyes of referring clinicians.
The results of the data analysis have provided me with direction into the possible mechanisms of microvascular dysfunction. I have a better understanding of this population and this data is guiding further research opportunities within the CVIP.
Outcomes
The research fellowship discovered that patients who are referred to CVIP for suspected functional CAD are not completely representative of the overall population of patients who have angina and normal angiograms. Data from CorHealth, a provincial reporting centre was analyzed and when compared to the CVIP patients it was determined that CVIP receives referrals for mostly women who are younger, of white ethnicity, with less incidence of traditional cardiovascular risk factors, more chronic inflammatory conditions and more psychiatric conditions. This represents a referral bias that is not congruent with the current literature on patients with functional CAD. Current data supports the development of functional CAD in the older population, men, non-white ethnicities, and those with significant traditional cardiovascular risk factors among others. Therefore, there is a large portion of patients who likely have functional CAD and who are not being seen in CVIP and therefore, not being diagnosed or managed appropriately. This was presented to the interprofessional team with the intention to educate others so that clinicians will be more mindful of the patient characteristics that should be considered when referring to CVIP for further diagnosis and management. Data from this fellowship was also included in a Heart and Stroke Foundation application grant. The grant proposal included a comprehensive approach to the research of this patient population with the intention to develop a mechanistic understanding of the disease process at the organ, cellular, and biochemical level. This research will aid in the proper diagnosis and treatment for this population with the overall intention to improve patient outcomes. The Heart and Stroke application acceptance was pending at the time that the executive summary was produced.
The results of the fellowship data analysis were presented to the interdisciplinary members at SRHC which included cardiologists and nurses in the cardiac program. As part of the presentation evaluation participants were asked to rate their knowledge of functional CAD (microvascular dysfunction) prior to the presentation and again after the presentation. These results were analyzed and showed that knowledge translation increased significantly from pre to post presentation (p<0.001). Pre presentation knowledge ranged from no knowledge (8%), little knowledge (19%), some knowledge (58%), lots of knowledge (8%), and extensive knowledge (8%). Knowledge increased post presentation to no knowledge (0%), little knowledge (0%), some knowledge (15%), lots of knowledge (54%), and extensive knowledge (31%), p <0.001. Participants were then asked whether their clinical practice would change when caring for this patient population as a result of the knowledge gained from the presentation and the results showed that 43% of the participants were likely to change their practice and 55% will somewhat change their practice. Finally participants were asked whether they were more likely to refer their patients with angina and non-obstructive CAD to CVIP for further coronary physiological testing and this analysis revealed that 58% of participants were more likely to refer. These results show that the presentation had a significant impact in terms of knowledge translation to key stakeholders and in turn this will increase referrals to CVIP which will improve the care of this undertreated population.
Lastly, parts of these research results were shared in a grant proposal to the Heart & Stroke Foundation. If this application is accepted, SRHC will be performing some of the world’s first research in distinct areas of functional CAD which have currently never been studied.
Overall experience
The opportunity to have dedicated time to conduct research with the overall intention to gain a better understanding of functional CAD and improve patient care to a historically misunderstood patient population was invaluable. I have been the NP in CVIP since the program was created in 2017 and as functional CAD is not a condition which is taught in undergraduate or graduate programs, I found myself yearning for an avenue where I could learn more about this disease. Clinical practice guidelines for this condition do not exist, so having a solid understanding of the current existing literature is an important first step to guide future directions for research. Having supportive and passionate mentors challenged me to always be thinking critically throughout the entire fellowship experience. My initial intentions were to identify the baseline characteristics of patients with functional CAD and decipher the differences between those with atherosclerotic CAD. As the fellowship progressed, so did my ideas for further research and I was able to develop new research questions. I also had time to analyze the follow-up data of our patients to see whether the treatment plan was making a positive impact. This is important as it provided an understanding of the unique characteristics of patients who improve, and those who do not.
\sOne of the most memorable moments occurred during data analysis. It was the beginning of analysis and I specifically remember the excitement that I felt when I was finding significant differences in the populations of interest (significant P values!). I immediately reviewed these results with my mentors as I wanted to share this excitement with the team. Some hiccups in the database proved to be challenging and required a significant amount of my time to review each variable for accuracy. Although this was not anticipated, it was a valuable lesson and experience as it reinforced the need for an accurate database in order to trust the research results.
