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OBJECTIVES—To describe the prevalence of Rose angina and non-exertional chest pain in men and women in socioeconomically contrasting areas; to describe the proportions of men and women who present with the symptom of chest pain and who receive a provisional general practitioner diagnosis of coronary heart disease; to assess the effects of gender and deprivation.
DESIGN—Two random general population samples in socially contrasting areas were surveyed using the Rose angina questionnaire: the case notes of people identified with chest pain were reviewed.
SETTING—Glasgow conurbation.
PARTICIPANTS—1107 men and women, aged 45-64, with chest pain.
OUTCOME MEASURES—Prevalence of Rose angina and non-exertional chest pain; the proportions who had presented with chest pain and received a general practitioner's provisional diagnosis of coronary heart disease.
RESULTS—There was no difference between social groups in the prevalence of all chest pain but a greater proportion of those in deprived groups had Rose angina and a greater proportion of these had the more severe grade. The proportion of people who had presented with chest pain was higher among socioeconomically deprived groups but there was no difference in the proportions receiving a general practitioner provisional diagnosis of coronary heart disease. Men were more likely to present with chest pain than women and were more likely to receive a provisional general practitioner diagnosis of coronary heart disease.
CONCLUSIONS—No evidence was found of social differences in patient presentation or general practitioner diagnosis that might explain reported variations in uptake of cardiology services. In contrast, gender variation may originate in part from differences in patient presentation and general practitioner diagnosis. Further investigation of socioeconomic variations in uptake of cardiology services should focus later in the care pathway, on general practitioner referral patterns and clinical decisions taken in secondary care.


Keywords: angina; social class; gender; primary care; chest pain

BACKGROUND: Chest pain is the main symptom of first presentation with ischaemic heart disease (IHD). Little is known about the incidence of IHD among patients consulting the general practitioner (GP) for chest pain. AIMS: To estimate the occurrence of IHD among patients consulting for chest pain, to study the results of the bicycle exercise test, and to estimate the incidence of IHD in the population. DESIGN OF STUDY: Prospective descriptive study. SETTING: Three primary health centres in south-eastern Sweden. METHOD: All patients without a current IHD diagnosis, aged 20 to 79 years, and consulting for a new episode of chest pain, were included consecutively. The outcome was classified as IHD, possible IHD or not IHD, according to the results of a postal questionnaire, an exercise test or hospital care. Data from the hospital registry on patients with a diagnosis of IHD were analysed retrospectively. RESULTS: Out of 38,075 GP consultations, 577 (1.5%) were for chest pain. IHD was diagnosed in 41 (8%) of the chest pain patients, in 441 (83%) the diagnosis was excluded, and in 50 (9%) the diagnosis was judged as being uncertain. Even though the diagnostic criteria were strict, the exercise tests led to a diagnostic conclusion in 77% of the cases, most frequently a normal test result. Combining data from primary and hospital care, the yearly incidence of IHD was 6.5 diagnosed per 1000 inhabitants (aged 20 to 79 years old). CONCLUSION: The incidence of a new episode of chest pain bringing the patients to the GP was low. Eight per cent of the patients received an IHD diagnosis, and in 9% further investigation or clinical assessment is needed.

Background

The diagnosis of angina is challenging as it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding.

Objective

To test the hypothesis that NLP of the EMR improves angina pectoris (AP) ascertainment over diagnostic codes.

Methods

Billing records of in- and out-patients were searched for ICD-9 codes for AP, chronic ischemic heart disease and chest pain. EMR clinical reports were searched electronically for 50 specific non-negated natural language synonyms to these ICD-9 codes. The two methods were compared to a standardized assessment of angina by Rose questionnaire for three diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina.

Results

Compared to the Rose questionnaire, the true positive rate of EMR-NLP for unspecified chest pain was 62% (95%CI:55–67) vs. 51% (95%CI:44–58) for diagnostic codes (p<0.001). For exertional chest pain, the EMR-NLP true positive rate was 71% (95%CI:61–80) vs. 62% (95%CI:52–73) for diagnostic codes (p=0.10). Both approaches had 88% (95%CI:65–100) true positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over 28-month follow-up.

Conclusion

EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

Background

Subjects with rheumatoid arthritis have an increased prevalence of ischaemic heart disease (IHD). This is most likely in those people with the autoantibody rheumatoid factor (RF). RF is strongly associated with rheumatoid arthritis (RA) but is also present in up to 15% of all adults.

Objective

To determine whether RF might identify people in a general population who also share an increased likelihood of developing IHD.

Methods

Subjects from the Hertfordshire Cohort Study were investigated for the presence of RF. Subjects completed a questionnaire and attended a clinic where a history of IHD was recorded (ECG, coronary artery bypass grafting, Rose chest pain). Associations between the presence of RF, antinuclear antibodies (ANA), anticardiolipin antibodies (ACA) and IHD in 567 men and 589 women were investigated and compared with traditional risk factors for IHD.

Results

RF was associated with an increased likelihood of IHD in men (odds ratio (OR) = 3.1, 95% CI 1.7 to 5.4, p<0.001). This increased risk could not be explained by traditional risk factors for IHD (mutually adjusted OR for RF 2.9 (95% CI 1.6 to 5.3), p<0.001). There was no significant association between RF in women or between ANA or ACA with IHD in men or women.

Conclusion

This work suggests that RF is an independent risk factor for IHD in the general population. It lends support to the importance of inflammation in atherosclerosis and suggests that autoimmune processes may be involved. In addition, it raises the intriguing possibility that RF may have a direct role in the pathogenesis of IHD in some subjects.

Recent research suggested associations between pain and subsequent all-cause and cancer-specific mortality. This study examined death and cancer development within six years of reporting pain, among women in the Royal College of General Practitioners Oral Contraception Study. We found no associations between 'any' or 'chronic' pain and subsequent all-cause mortality or cancer. We found a higher risk of death from respiratory disease among women reporting pain (adjusted odds ratio [AOR] = 2.5), a higher mortality among women reporting chronic chest pain (AOR = 1.75), and a higher risk of subsequent cancer among women reporting head or abdomen pain. Given the high prevalence of pain symptoms, these findings may be important, and warrant further research.

Objective: To assess the performance of a shortened version of the Rose angina questionnaire focusing on exertional chest pain.

Methods: Cross sectional analysis of 3987 women aged 60 to 79 years from 23 British towns. The performances of definite Rose angina (using data from the full Rose angina questionnaire) and exertional chest pain (using data from a subset of three questions from the Rose angina questionnaire) were assessed against a medical record of angina.

Results: The sensitivity (the proportion with a medical record of angina who were identified as having angina by the questionnaire) was 29.9% (95% confidence intervals 25.7% to 34.4%) comparing definite Rose angina to any medical record of angina since 1978 and 50.7% (45.9% to 55.5%) comparing exertional chest pain to any medical record diagnosis of angina. The positive predictive values of both questionnaires were similar. When the two questionnaires were compared with a gold standard of a primary care consultation for angina symptoms within the past five years the sensitivity of definite Rose angina was 33.0% (26.9% to 39.6%) and that of exertional chest pain was 51.8% (45.1% to 58.5%). Although the sensitivity of both versions of the questionnaire was greater in those aged 60–69 years compared with those aged 70–79 years, it remained higher in the exertional chest pain version of the questionnaire than for definite Rose angina based on the full version of the questionnaire in both age groups. Performance of either version of the questionnaire was not affected by occupational social class.

Conclusions: With respect to identifying women with a medical diagnosis of angina or those presenting to primary care with anginal symptoms, these results suggest that a shortened version of the Rose angina questionnaire focusing on exertional chest pain performs better than the full version. Other studies suggest that exertional chest pain is the crucial element of the Rose angina questionnaire with respect to predicting future coronary events. It is concluded that using a shortened version of the Rose angina questionnaire is adequate in epidemiological studies.

OBJECTIVE--To determine whether Helicobacter pylori infection is associated with the development of ischaemic heart disease and whether such infection can explain the social class inequality in ischaemic heart disease. DESIGN--Cardiovascular risk factor levels, prevalence of ischaemic heart disease (Rose questionnaire angina, and/or a history of myocardial infarction), and serum antibodies to H pylori (enzyme linked immunosorbent assay) were assessed in a cross sectional population based survey. SETTING--Belfast and surrounding districts, Northern Ireland. PARTICIPANTS--1182 men and 1198 women aged 25-64 years randomly selected from the Central Services Agency's general practitioner lists. MAIN OUTCOME MEASURES--The relation of H pylori infection with cardiovascular risk factors and ischaemic heart disease. The association of social class with ischaemic heart disease. RESULTS--Systolic and diastolic blood pressure, plasma viscosity, and total cholesterol were not associated with H pylori infection. A weak negative association existed between H pylori infection and fibrinogen (mean (SE) difference in fibrinogen between infected and uninfected individuals -0.09 (0.04) g/l, P = 0.02) and between infection in women and high density lipoprotein (HDL) cholesterol (mean (SE) difference in HDL cholesterol between infected and uninfected individuals -0.06 (0.02) mmol/l, P = 0.006). A potentially important association was demonstrated between H pylori infection and ischaemic heart disease but this did not reach statistical significance (odds ratio (95% confidence interval (CI) 1.51 (0.93 to 2.45), P = 0.1). Social class was associated with ischaemic heart disease independently of cardiovascular risk factors and H pylori infection (odds ratio, manual v non-manual (95% CI) 1.82 (1.14 to 2.91), P = 0.01). CONCLUSION--H pylori may be independently associated with the development of ischaemic heart disease but if this is so the mechanism by which this effect is exerted is not through increased concentration of plasma fibrinogen. H pylori infection does not explain the social class inequality in ischaemic heart disease which exists independently of known cardiovascular risk factors.

Data from 10,359 men and women aged 40-59 years from 22 districts in the Scottish Heart Health Study were used to describe the prevalence rates of coronary heart disease in Scotland in 1984-1986 and their relation to the geographical variation in mortality in these districts. Prevalence was measured by previous history, Rose chest pain questionnaire, and the Minnesota code of a 12 lead resting electrocardiogram. The prevalence of coronary heart disease in Scotland was high compared with studies from other countries that used the same standardised methods. A history of angina was more common in men (5.5%) than in women (3.9%), though in response to the Rose questionnaire 8.5% of women and 6.3% of men reported chest pain. A history of myocardial infarction was three times more common in men than women, as was a Q/QS pattern on the electrocardiogram. There were significant correlations between the different measures of coronary prevalence. District measures of angina correlated well with mortality from coronary heart disease, and these correlations tended to be stronger in women than in men. There was no significant correlation between mortality from coronary heart disease and measures of myocardial infarction. The study provides data on the prevalence of coronary heart disease in men and women that are valuable for the planning of cardiological services.

OBJECTIVE: To determine whether the rate of cardiovascular disease is different among parous women with a general practitioner reported history of toxaemia of pregnancy than among those not reported to have experienced toxaemia, or among nulliparous women. DESIGN: Prospective cohort study. SETTING: 1400 general practitioners throughout the United Kingdom. SUBJECTS: Women who had never used oral contraceptives who were recruited to the Royal College of General Practitioners' oral contraception study (original cohort about 23000). MAIN OUTCOME MEASURES: Age, social class, and smoking standardised incidence rates for hypertensive disease, acute myocardial infarction, other acute ischaemic heart disease, other chronic ischaemic heart disease, angina pectoris, total ischaemic heart disease, total cerebrovascular disease, and total venous thromboembolic disease in the three groups. RESULTS: Compared with parous women with no history of toxaemia, those who had experienced toxaemia had a significantly increased risk of hypertensive disease (relative risk (RR) 2.35), acute myocardial infarction (RR 2.24), chronic ischaemic heart disease (RR 1.74), angina pectoris (RR 1.53), all ischaemic heart disease (RR 1.65), and venous thromboembolism (RR 1.62). The rates for all cerebrovascular disease and peripheral vascular disease were also increased but not significantly. Nulliparous women were more likely to develop hypertension or all cerebrovascular disease later in life than parous women without a history of toxaemia. CONCLUSIONS: A history of toxaemia of pregnancy increases the risk of several distinct cardiovascular conditions later in life. Although causality cannot be inferred (other characteristics of the women may account for both an increased risk of toxaemia and a risk of subsequent vascular disease), the findings merit further research because of their potential importance.

Background

Whether the higher coronary mortality in South Asians compared with White populations is due to a higher incidence of disease is not known. This study assessed cumulative incidence of chest pain in South Asians and Whites, and prognosis of chest pain.

Methods

Over seven phases of 18-year follow-up of the Whitehall-II study (9775 civil servants: 9195 White, 580 South Asian), chest pain was assessed using the Rose questionnaire. Coronary death/non-fatal myocardial infarction was examined comparing those with chest pain to those with no chest pain at baseline.

Results

South Asians had higher cumulative frequencies of typical angina by Phase 7 (17.0 versus 11.3%, P < 0.001) and exertional chest pain (15.4 versus 8.5%, P < 0.001) compared with Whites. Typical angina and exertional chest pain at baseline were associated with a worse prognosis compared with those with no chest pain in both groups (typical angina, South Asians: HR, 4.67 and 95% CI, 2.12–0.30; Whites: HR, 3.56 95% CI, 2.59–4.88). Baseline non-exertional chest pain did not confer a worse prognosis. Across all types of pain, prognosis was worse in South Asians.

Conclusion

South Asians had higher cumulative incidence of angina than Whites. In both, typical angina and exertional chest pain were associated with worse prognosis compared with those with no chest pain.

Objective

To examine the long‐term cardiovascular consequences of angina in a large epidemiological study.

Design

Prospective cohort study conducted between 1972 and 1976 with 20 years of follow‐up (the Renfrew–Paisley Study).

Setting

Renfrew and Paisley, West Scotland, UK.

Participants

7048 men and 8354 women aged 45–64 years who underwent comprehensive cardiovascular screening at baseline, including the Rose Angina Questionnaire and electrocardiography (ECG).

Main outcome measures

All deaths and hospitalisations for cardiovascular reasons occurring over the subsequent 20 years, according to the baseline Rose angina score and baseline ECG.

Results

At baseline, 669 (9.5%) men and 799 (9.6%) women had angina on Rose Angina Questionnaire. All‐cause mortality for those with Rose angina was 67.7% in men and 43.3% in women at 20 years compared with 45.4% and 30.4%, respectively, in those without angina (p<0.001). Values are expressed as hazards ratio (HR) (95% confidence interval (CI). In a multivariate analysis, men with Rose angina had an increased risk of cardiovascular death or hospitalisation (1.49 (1.33 to 1.66), myocardial infarction (1.63 (1.41 to 1.85)) or heart failure (1.54 (1.13 to 2.10)) compared with men without angina. The corresponding HR (95% CI) for women were 1.38 (1.23 to 1.55), 1.56 (1.31 to 1.85) and 1.92 (1.44 to 2.56). An abnormality on the electrocardiogram (ECG) increased risk further, and both angina and an abnormality on the ECG increased risk most of all compared with those with neither angina nor ischaemic changes on the ECG. Compared with men, women with Rose angina were less likely to have a cardiovascular event (0.54 (0.46 to 0.64)) or myocardial infarction (0.44 (0.35 to 0.56)), although there was no sex difference in the risk of stroke (1.11 (0.75 to 1.65)), atrial fibrillation (0.84 (0.38 to 1.87)) or heart failure (0.79 (0.51 to 1.21)).

Conclusions

Angina in middle age substantially increases the risk of death, myocardial infarction, heart failure and other cardiovascular events.

The mortality rate from ischaemic heart disease (I.H.D.) has increased in young women by about 50% in 12 years, and it is now possible to report the findings in 150 women who developed symptoms and signs of I.H.D. under the age of 45. Data obtained from 145 of these women form the basis of this report: 81 presented with myocardial infarction and 64 with angina. In the remaining five there was a definite nonatherosclerotic cause for the premature onset of I.H.D.

Hypercholesterolaemia, hypertension, or excessive cigarette smoking each occurred in a large minority, and more than one of these major risk factors was present in most patients. Hypercholesterolaemia was the commonest factor. In women in whom lipoprotein typing was undertaken the type II pattern was more frequent than type IV. The prevalence of hypercholesterolaemia and hypertension was the same in those with myocardial infarction and in those with angina.

Excessive cigarette smoking was more common in women with myocardial infarction than in those with angina. The latter did not differ in their cigarette smoking habits from the normal population.

A premature menopause had occurred in 20% of these women, but there was no relation between the early onset of I.H.D. with age at menarche, parity, or the incidence of abortion. Oral contraceptives did not increase the risk of myocardial infarction unless one of the major risk factors was also present.

Altogether 75% of patients with angina or myocardial infarction survived 12 years. Coexisting hypertension worsened the prognosis. The prognosis after myocardial infarction was similar in these women to that previously described for men under the age of 40.

A total of 18 403 men aged between 40 and 64 years took part in a screening examination which included a self-administered version of the London School of Hygiene questionnaire on chest pain and intermittent claudication. The yield of positives for "angina" and "history of possible infarction" was about twice as high as with interviewers, but the positive groups obtained by the two techniques differed little in their association with electrocardiographic findings or in their ability to predict five-year coronary mortality risk. This risk ranged from 0-9% in men negative to questionnaire and electrocardiograms (ECG), to 4-3% for those with positive ECG but no symptoms, 4-5% for those with angina and negative ECG, up to 16% for those with angina and positive ECG. The self-administered version of this questionnaire provides a simple and convenient means of identifying individuals with a high risk of major coronary heart disease.

Background

Chest pain may not be reported to general practice but could be an important first sign of coronary heart disease (CHD).

Aims

To determine whether self-reported chest pain predicts future consultation for CHD in those with no history of consultation for CHD.

Design of study

Population-based study, with 7 year's follow up by GP record linkage.

Setting

General practice in North Staffordshire.

Method

A survey, including the Rose angina questionnaire, was mailed to 4002 adults. Linked GP records used to identify responders with no record of CHD (G3 Read code or British National Formulary code for nitrate use) in the 32 months before the survey to form the sample for a 7-year prospective study. ‘Survival’ was compared in those with and without self-reported chest pain up to the earliest date of GP diagnosis of CHD, death, or end of the study period.

Results

The survey response was 65% and 2348 participants gave permission to access their GP records. Of these, 2229 had no prior consultation for CHD. From the questionnaire, 558 reported chest pain of which 186 reported exertional pain and 103 met the criteria for angina. When followed prospectively, incidence of CHD consultations was higher in those with any chest pain definition, compared with no pain, and continued to be so for 7 years subsequently. Although these associations were strongly age related, self-reported symptoms were found to be an independent risk factor for future consultation for CHD.

Conclusion

This study highlighted that self-reported chest pain is a marker of future CHD. The usefulness of early identification of people with this symptom remains to be established.

Aims: To determine whether an increase in effort-reward imbalance over time increases the risk of angina, and whether such increases are associated with lower occupational position.

Methods: Effort-reward imbalance (ERI) at work was measured in the Whitehall II occupational cohort of London based civil servants at baseline (1985–88) and in 1997. Coronary heart disease was measured in a self-reported health questionnaire by combining the Rose Angina Questionnaire with doctor diagnosed angina in 2001.

Results: Among men, increase in ERI over time was associated with an increased risk of incident angina. Moreover, as increases in ERI were more common among lower grade civil servants, change in imbalance, to some extent, contributed to explaining the social gradient in angina. Among women, increases in imbalance were not associated with risk of angina, and therefore did not contribute to the explanation of the social gradient.

Conclusions: Reductions in effort-reward imbalance at work may reduce the risk of coronary heart disease among men.

Abstract

Objective

To study the sex-specific association of angina pectoris with mortality in community-dwelling older adults with and without diabetes.

Methods

Baseline prevalence of angina was evaluated in 822 men and 1184 postmenopausal women aged 50–89 years at the 1984–1987 Rancho Bernardo Study clinic visit, when an oral glucose tolerance test (OGTT) and the Rose angina questionnaire were administered. All-cause and coronary heart disease (CHD) mortality were assessed after an average follow-up period of 13.2 years. Sex-specific Cox proportional hazard models were used to examine the independent association of angina with mortality by glucose tolerance category.

Results

At baseline, average age was 71 years for both sexes; 61 men (7.4%) and 142 women (12.0%) had angina. Overall, 129 men (15.9%) and 130 women (11.0%) had type 2 diabetes; 228 men (27.7%) and 357 women (30.2%) had impaired glucose tolerance (IGT). During follow-up, 485 men (59%) and 557 women (47%) died, of whom 103 men (21.2%) and 104 women (18.7%) had fatal CHD. Women with diabetes and angina had a 3–4-fold greater risk of dying from CHD than women with diabetes but without angina, independent of covariates. Women with angina and IGT had twice the risk of CHD mortality compared with women with IGT but without angina. A smaller increased risk of fatal CHD in men was not statistically significant.

Conclusions

Angina was associated with an increased risk of dying from CHD among women, especially among those who also had IGT or diabetes.

OBJECTIVE: To determine the association between adverse psychosocial characteristics at work and risk of coronary heart disease among male and female civil servants. DESIGN: Prospective cohort study (Whitehall II study). At the baseline examination (1985-8) and twice during follow up a self report questionnaire provided information on psychosocial factors of the work environment and coronary heart disease. Independent assessments of the work environment were obtained from personnel managers at baseline. Mean length of follow up was 5.3 years. SETTING: London based office staff in 20 civil service departments. SUBJECTS: 10,308 civil servants aged 35-55 were examined-6895 men (67%) and 3413 women (33%). MAIN OUTCOME MEASURES: New cases of angina (Rose questionnaire), severe pain across the chest, diagnosed ischaemic heart disease, and any coronary event. RESULTS: Men and women with low job control, either self reported or independently assessed, had a higher risk of newly reported coronary heart disease during follow up. Job control assessed on two occasions three years apart, although intercorrelated, had cumulative effects on newly reported disease. Subjects with low job control on both occasions had an odds ratio for any subsequent coronary event of 1.93 (95% confidence interval 1.34 to 2.77) compared with subjects with high job control at both occasions. This association could not be explained by employment grade, negative affectivity, or classic coronary risk factors. Job demands and social support at work were not related to the risk of coronary heart disease. CONCLUSIONS: Low control in the work environment is associated with an increased risk of future coronary heart disease among men and women employed in government offices. The cumulative effect of low job control assessed on two occasions indicates that giving employees more variety in tasks and a stronger say in decisions about work may decrease the risk of coronary heart disease.

The Bortner questionnaire, which measures aspects of type A (coronary prone) behaviour was completed by 5936 men aged 40-59 selected at random from one general practice in each of 19 British towns. The presence of ischaemic heart disease was determined at initial examination and the men were followed up for an average of 6.2 years for morbidity and mortality from myocardial infarction and for sudden cardiac death. Non-manual workers had significantly higher scores (more type A) than manual workers and the score decreased (less type A) with increasing age. After adjustment for social class and age men with higher scores had higher prevalences of ischaemic heart disease less marked for electrocardiographic evidence and more marked for response to a chest pain questionnaire (angina or possible myocardial infarction). A man's recall of a doctor's diagnosis of ischaemic heart disease, however, did not relate to his Bortner score. There was no significant relation between the Bortner score and the attack rate or incidence of major ischaemic heart disease events. In this study type A behaviour, as measured by the Bortner questionnaire, did not predict major ischaemic heart disease events in British middle aged men.

STUDY OBJECTIVE: To determine whether changes in smoking status among women recruited for the Royal College of General Practitioners' Oral Contraception Study affected previous risk estimates for myocardial infarction. DESIGN: (1) Postal survey between November 1994 and July 1995 of women still under general practitioner observation. Validation of the smoking information supplied by the women on the questionnaire by comparison with that reported by the general practitioner at recruitment to the main study. (2) Nested case-control study of 103 cases of myocardial infarction, matched with 309 controls, to see if different risk estimates were obtained when smoking status at recruitment or smoking status at time of event were used in the analysis. SETTING: 650 general practices throughout the United Kingdom. PARTICIPANTS: 10,073 women who responded to the questionnaire (85.4% of 11,797 sent out). MAIN RESULTS: There was good agreement between smoking information recorded by the general practitioner at recruitment and that supplied retrospectively by respondents to the questionnaire. The risk estimates for myocardial infarction associated with use of combined oral contraceptives (COCs) were almost identical irrespective of whether smoking status at recruitment or at time of event was used for the statistical adjustment. This was because few women stopped smoking while also using COCs. In fact, fewer regular smokers who have ever used COCs reported stopping smoking than never users. The risk estimates for myocardial infarction associated with smoking were smaller when smoking habits at recruitment was used than when smoking habits at time of event was used. CONCLUSIONS: Previous results from the Oral Contraception Study regarding the effects of COCs are unlikely to have been biased by changes in the smoking habits of the cohort, but the effects of smoking have probably been underestimated. There is still a need for effective health education regarding the risks associated with smoking, particularly among users of COCs.

 

In a study of the prevalence of ischaemic heart disease in middle aged men in 24 British towns, the subjects were asked whether a doctor had ever told them that they had any form of cardiovascular disease. Their recall of various diagnoses was related to evidence of ischaemic heart disease obtained by an administered questionnaire on chest pain and electrocardiography. Twenty one per cent of men recalled a diagnosis of cardiovascular disease, in one quarter of whom it was ischaemic heart disease. There was a sixfold increase in the prevalence of recall of a diagnosis of ischaemic heart disease over the age range studied. Only one third of the men with possible myocardial infarction on questionnaire recalled such a diagnosis having been made by a doctor. Only half of those with a definite myocardial infarction on an electrocardiogram could recall a diagnosis of ischaemic heart disease. Even in severe (grade 2) angina 40% could not recall being told that they had heart disease. Overall, only one in five of those regarded as having ischaemic heart disease was able to recall such a diagnosis having been made by a doctor, and these were likely to be those most severely affected. Ischaemic heart disease is common in middle aged British men, but most of those affected are apparently not aware of their condition. This low level of awareness among patients and doctors may contribute to a lack of public concern regarding the need for action to reduce the incidence of ischaemic heart disease in Great Britain.

Objective: To determine whether men with possible angina (from their responses to the World Health Organization angina questionnaire) but a normal exercise ECG differ in long term rates of coronary heart disease events from men with no symptoms of angina.

Design: During 1972–75, 2014 apparently healthy men aged 40–59 years underwent an examination programme including case history, clinical examination, exercise ECG to exhaustion, and various other tests. All men completed the WHO angina questionnaire.

Subjects: Of 2014 men, 68 had possible angina, 1831 had no symptoms of angina, and 115 were excluded because they had definite angina or pathological exercise ECGs. All 68+1831 had normal exercise ECGs and none developed chest pain during the exercise test.

Results: At 26 years, men with possible angina had a coronary heart disease mortality of 25.0% (17/68) v 13.8% (252/1831) among men with no symptoms of angina (p < 0.013). They also had a higher incidence of coronary artery bypass grafting (CABG) (p < 0.0004) and acute myocardial infarction (p < 0.026). The excess coronary heart disease mortality among men with possible angina only started after 15 years, whereas differences in CABG/acute myocardial infarction started early. Multivariate analysis including well recognised coronary heart disease risk factors showed that possible angina was an independent risk factor (relative risk 1.79, 95% confidence interval 1.26 to 2.10).

Conclusions: Men with possible angina, even with a normal exercise test, have a greater risk of dying from coronary heart disease, having an acute myocardial infarct, or needing a CABG than age matched counterparts with no symptoms of angina.

Objective—To evaluate the effects of α tocopherol and β carotene supplements on recurrence and progression of angina symptoms, and incidence of major coronary events in men with angina pectoris.
Design—Placebo controlled clinical trial.
Setting—The Finnish α tocopherol β carotene cancer prevention study primarily undertaken to examine the effects of α tocopherol and β carotene on cancer.
Subjects—Male smokers aged 50-69 years who had angina pectoris in the Rose chest pain questionnaire at baseline (n = 1795).
Interventions—α tocopherol (vitamin E) 50 mg/day, β carotene 20 mg/day or both, or placebo in 2 × 2 factorial design.
Main outcome measures—Recurrence of angina pectoris at annual follow up visits when the questionnaire was readministered; progression from mild to severe angina; incidence of major coronary events (non-fatal myocardial infarction and fatal coronary heart disease).
Results—There were 2513 recurrences of angina pectoris during follow up (median 4 years). Compared to placebo, the odds ratios for recurrence in the active treatment groups were: α tocopherol only 1.06 (95% confidence interval (CI) 0.85 to 1.33), α tocopherol and β carotene 1.02 (0.82 to 1.27), β carotene only 1.06 (0.84 to 1.33). There were no significant differences in progression to severe angina among the groups given supplements or placebo. Altogether 314 major coronary events were observed during follow up (median 5.5 years) and the risk for them did not differ significantly among the groups given supplements or placebo.
Conclusions—There was no evidence of beneficial effects for α tocopherol or β carotene supplements in male smokers with angina pectoris, indicating no basis for therapeutic or preventive use of these agents in such patients.

 Keywords: antioxidants;  angina pectoris;  prevention;  vitamin supplements

A group of 215 men and 272 women aged 62 to 90 forming a randomly-selected sample of the older population was studied by cardiovascular survey methods and followed for 5 years. The 5-year mortality of 28 per cent was related to age and was higher in men. Ischaemic heart disease was the certified cause of 28 per cent of the deaths. Mortality was greater in those with systolic hypertension. Among electrocardiographic features ST depression, T inversion, and atrial fibrillation increased overall and ischaemic heart disease mortality independently of their association with age. A positive response to an angina and infarct questionnaire was poorly related to subsequent mortality. Re-examination of 72 per cent of 5-year survivors was possible. Systolic and diastolic blood pressures were significantly lower and the frequency of electrocardiographic abnormalities, particularly left axis deviation, left ventricular hypertrophy, and ST and T wave changes, was increased.

Aim

This paper reports findings of a study to examine the independent contribution of chest pain, fatigue, and dyspnea to health-related quality of life in patients with chronic stable angina.

Background

Patients with chronic stable angina experience poorer quality of life in multiple areas including physical and emotional health. Emerging evidence suggests the presence of concomitant symptoms, yet there are no systematic studies examining the impact of symptom clusters on quality of life in chronic angina patients.

Method

Outpatients (n=134), recruited over a 16 month period in 2000 and 2001, with confirmed coronary heart disease and chronic angina completed reliable and valid questionnaires measuring chest pain frequency, fatigue, dyspnea and quality of life. Hierarchical multiple linear regression was used to examine the symptom cluster of chest pain frequency, fatigue, and dyspnea in predicting quality of life.

Results

The sample was predominantly white (74.6%), males (59.7%) with a mean age of 63.4 (SD 12.12) years. Controlling for age, gender, social status, and comorbidities, the symptom cluster of chest pain frequency, dyspnea, and fatigue accounted for significant increase in unadjusted R2, (F of Δ, p < .05) for the models predicting physical limitation (R2 Δ 24.1%), disease perception (R2 Δ 24.6%), Short Form-36 Physical Component Score (R2 Δ 24.3%) and Mental Component Score (R2 Δ 07.0%).

Conclusion

Symptom assessment and management of patients with chronic stable angina should involve multiple symptoms. Greater fatigue predicted poorer quality of life in multiple areas. As a possible indicator of depression, it warrants further assessment and follow-up.

A newly developed, highly sensitive immunoassay for creatine kinase MB isoenzyme was evaluated in 68 patients with or without different types of ischaemic heart disease. Patients were classified on the basis of clinical criteria in four groups: no ischaemic heart disease, stable angina, unstable angina, and acute myocardial infarction. Enzyme concentration in patients with stable angina was the same (even during exercise) as seen in the patients without ischaemic heart disease. Patients with unstable angina, however, could be divided into two groups. One group showed clear evidence of severe myocardial ischaemia by serial changes and higher mean values of creatine kinase MB up to 40 hours after the onset of symptoms, whereas in the remainder values were stable and resembled those seen in the patients without ischaemic heart disease. The changes in concentration correlated with signs of repetitive ischaemic episodes deduced from continuous ST segment monitoring during the first 24 hours after admission. These findings indicate that patients with unstable angina are a heterogenous group. In some, severe and prolonged ischaemia can be detected by a serological assay with high sensitivity.