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[Symptoms and natural history of cardiovascular diseases: obsolete?]
1Hôpital cardiologique, BP Lyon-Montchat.
Insights
Cardiovascular disease diagnosis increasingly relies on tests over symptoms. Re-emphasizing symptom assessment and understanding natural disease history is crucial for effective patient care and treatment decisions.
Area of Science:
- Cardiology
- Diagnostic Medicine
- Clinical Epidemiology
Background:
- The diagnostic role of symptoms in cardiovascular diseases has diminished.
- Current practices often prioritize intervention over understanding the natural history and spontaneous outcomes of cardiovascular conditions.
- While presymptomatic diagnosis and treatment offer benefits in specific cases (e.g., asymptomatic aortic regurgitation, silent ischemia), risks associated with misinterpretation and over-intervention exist.
Discussion:
- Underassessment of patient complaints and excessive, context-lacking investigations can lead to diagnostic errors.
- Patient-driven treatment choices and inadequate education on therapeutic options can result in suboptimal care.
- The pursuit of intermediate physiological or anatomical goals, without proven impact on longevity or quality of life, is a concern.
Key Insights:
- There is a disproportion between the limited number of validated therapies and the increasing number of interventions for asymptomatic patients.
- Re-establishing the teaching of general pathology and the natural history of cardiovascular diseases is essential.
- Symptom assessment in cardiovascular diagnosis should integrate physiopathological understanding, Bayesian predictive value analysis, and multiparameter scoring.
Outlook:
- Future cardiovascular diagnosis should balance advanced testing with a renewed emphasis on clinical judgment informed by pathophysiology and evidence-based scoring systems.
- Improved patient education and a focus on validated therapeutic outcomes are needed to guide treatment decisions.
- A more nuanced approach is required, considering both the benefits of early intervention and the potential for favorable spontaneous disease progression.
Abstract:
The role of symptoms in establishing a diagnosis in cardiovascular diseases has decreased. Treatment privileges action and underestimates the potentially favourable spontaneous outcome of the treated condition. The object of this article is not to question the progress made in presymptomatic diagnosis of certain cardiovascular diseases or the benefits of treatment prescribed for some a- or paucisymptomatic patients: recent reports, particularly in asymptomatic aortic regurgitation, silent ischemia and subclinical left ventricular dysfunction of cardiomyopathy have confirmed the utility of therapy in these cases. However, the risks of misinterpreting a symptom and the natural history should be underlined: the "complaint" of the patient not properly assessed; cascades of "complementary investigations" of debatable utility and uncertain interpretation, when taken out of context; substitution of the medical therapeutic offer on demand of the patient and inadequate patient education concerning possible therapeutic approaches: the quest for intermediary objectives (anatomic, physiologic, biologic), which have not been shown to increase the quality or duration of life; the disproportion between the small number of validated therapies and the ever increasing range of interventional audacities in asymptomatic patients... It is important that general pathology and the natural history of cardiovascular diseases are taught again in France. With respect to symptoms, proper assessment no longer depends on "clinical judgment"; it should have a greater role in diagnosis of cardiovascular diseases by the understanding of the physiopathological mechanisms, Bayesian assessment of its predictive value, and accurate inclusion in multiparameter scores derived from recent large scale epidemiologic and therapeutic trials.