Appropriateness criteria for coronary angiography in angina: reliability and validity

BACKGROUND

Evaluated criteria for tailoring the decision to perform coronary angiography in specific clinical scenarios are lacking.

OBJECTIVE

To determine the reliability and prognostic validity of patient-specific appropriateness criteria for coronary angiography among patients with suspected angina pectoris.

DESIGN

Prospective observational study. Two independent panels of clinicians scored 2400 patient-specific indications for coronary angiography as inappropriate, uncertain, or appropriate. Using a simple computer algorithm, patients were matched to 1 of these indications.

SETTING

6 urban ambulatory care clinics in the United Kingdom.

PATIENTS

9356 consecutive patients with recent-onset chest pain in whom stable angina was suspected.

MEASUREMENTS

Appropriateness ratings and clinical outcomes (coronary death and acute coronary syndrome events) over a median of 3 years of follow-up.

RESULTS

660 coronary deaths or acute coronary syndrome events occurred. Agreement between the 2 panels (reliability) on appropriateness category was moderate (weighted kappa = 0.58; P < 0.001). Use of subsequent angiography was strongly related to appropriateness category (P for linear trend <0.001) according to scores from either panel. Among patients judged as appropriate candidates for angiography, underuse was common (57% according to panel A and 71.3% according to panel B), and not undergoing coronary angiography was associated with higher coronary event rates than was undergoing the procedure. The hazard ratio after adjustment for age, sex, exercise electrocardiography result, and secondary prevention medication was similar according to panel A (2.78 [95% CI, 1.77 to 4.37]) and panel B (2.47 [CI, 1.72 to 3.55]).

LIMITATION

The study was too small to assess the relationship of angiography with coronary death and did not assess the reasons why patients did not receive angiography.

CONCLUSION

Appropriateness scores offer prognostically valid criteria for judging which specific patients might benefit from coronary angiography. Patient-specific appropriateness scores help pinpoint areas where judgments diverge and are a promising tool for making guidelines more effective.

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

OBJECTIVES

To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates.

DESIGN

Multicentre cohort with five year follow-up.

SETTING

Six ambulatory care clinics in England.

PARTICIPANTS

1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method.

MAIN OUTCOME MEASURES

Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.

RESULTS

In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.

CONCLUSIONS

At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.

Prevalence of Angina in Women Versus Men

Background— In the absence of previous international comparisons, we sought to systematically evaluate, across time and participant age, the sex ratio in angina prevalence in countries that differ widely in the rate of mortality due to myocardial infarction.

Methods and Results— We searched MEDLINE and EMBASE until February 2006 for healthy population studies published in any language that reported the prevalence of angina (Rose questionnaire) in women and men. We obtained myocardial infarction mortality rates from the World Health Organization. A total of 74 reports of 13 331 angina cases in women and 11 511 cases in men from 31 countries were included. Angina prevalence varied widely across populations, from 0.73% to 14.4% (population weighted mean 6.7%) in women and from 0.76% to 15.1% (population weighted mean 5.7%) in men, and was strongly correlated within populations between the sexes ( r =0.80, P <0.0001). Angina prevalence showed a small female excess with a pooled random-effects sex ratio of 1.20 (95% CI 1.14 to 1.28, P <0.0001). This female excess was found across countries with widely differing myocardial infarction mortality rates in women (interquartile range 12.7 to 126.5 per 100 000), was particularly high in the American studies (1.40, 95% CI 1.28 to 1.52), and was higher among nonwhite ethnic groups than among whites. This sex ratio did not differ significantly by participant’s age, the year the survey began, or the sex ratio for mortality due to myocardial infarction.

Conclusions— Over time and at different ages, independent of diagnostic and treatment practices, women have a similar or slightly higher prevalence of angina than men across countries with widely differing myocardial infarction mortality rates.

Performing stable angina pectoris: an ethnographic study

Symptoms play a crucial part in the formulation of medical diagnoses, yet the construction and interpretation of symptom narratives is not well understood. The diagnosis of angina is largely based on symptoms, but a substantial minority of patients diagnosed with "non-cardiac" chest pain go on to have a heart attack. In this ethnographic study our aims were to understand: (1) how the patients' accounts are performed or enacted in consultations with doctors; (2) the ways in which ambiguity in the symptom narrative is managed by doctors; and (3) how doctors reach or do not reach a diagnostic decision. We observed 59 consultations of patients in a UK teaching hospital with new onset chest pain who had been referred for a specialist opinion in ambulatory care. We found that patients rarely gave a history that, without further interrogation, satisfied the doctors, who actively restructured the complex narrative until it fitted a diagnostic canon, detaching it from the patient's interpretation and explanation. A minority of doctors asked about chest pain symptoms outside the canon. Re-structuring into the canonical classification was sometimes resisted by patients who contested key concepts, like exertion. Symptom narratives were sometimes unstable, with central features changing on interrogation and re-telling. When translation was required for South Asian patients, doctors considered the history less relevant to the diagnosis. Diagnosis and effective treatment could be enhanced by research on the diagnostic and prognostic value of the terms patients use to describe their symptoms.

Work stress and coronary heart disease: what are the mechanisms?

AIMS

To determine the biological and behavioural factors linking work stress with coronary heart disease (CHD).

METHODS AND RESULTS

A total of 10 308 London-based male and female civil servants aged 35-55 at phase 1 (1985-88) of the Whitehall II study were studied. Exposures included work stress (assessed at phases 1 and 2), and outcomes included behavioural risk factors (phase 3), the metabolic syndrome (phase 3), heart rate variability, morning rise in cortisol (phase 7), and incident CHD (phases 2-7) on the basis of CHD death, non-fatal myocardial infarction, or definite angina. Chronic work stress was associated with CHD and this association was stronger among participants aged under 50 (RR 1.68, 95% CI 1.17-2.42). There were similar associations between work stress and low physical activity, poor diet, the metabolic syndrome, its components, and lower heart rate variability. Cross-sectionally, work stress was associated with a higher morning rise in cortisol. Around 32% of the effect of work stress on CHD was attributable to its effect on health behaviours and the metabolic syndrome.

CONCLUSION

Work stress may be an important determinant of CHD among working-age populations, which is mediated through indirect effects on health behaviours and direct effects on neuroendocrine stress pathways.

European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts)

Other experts who contributed to parts of the guidelines: Edmond Walma, Schoonhoven (The Netherlands), Tony Fitzgerald, Dublin (Ireland), Marie Therese Cooney, Dublin (Ireland), Alexandra Dudina, Dublin (Ireland) European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG):, Alec Vahanian (Chairperson) (France), John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway), Christian Funck-Brentano (France), Gerasimos Filippatos (Greece), Irene Hellemans (The Netherlands), Steen Dalby Kristensen (Denmark), Keith McGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany), Michal Tendera (Poland), Petr Widimsky (Czech Republic), José Luis Zamorano (Spain)

Document reviewers: Irene Hellemans (CPG Review Coordinator) (The Netherlands), Attila Altiner (Germany), Enzo Bonora (Italy), Paul N. Durrington (UK), Robert Fagard (Belgium), Simona Giampaoli(Italy), Harry Hemingway (UK), Jan Hakansson (Sweden), Sverre Erik Kjeldsen (Norway), Mogens Lytken Larsen (Denmark), Giuseppe Mancia (Italy), Athanasios J. Manolis (Greece), Kristina Orth-Gomer (Sweden), Terje Pedersen (Norway), Mike Rayner (UK), Lars Ryden (Sweden), Mario Sammut (Malta), Neil Schneiderman (USA), Anton F. Stalenhoef (The Netherlands), Lale Tokgözoglu (Turkey), Olov Wiklund (Sweden), Antonis Zampelas (Greece)

European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts)

Other experts who contributed to parts of the guidelines: Edmond Walma, Tony Fitzgerald, Marie Therese Cooney, Alexandra Dudina

European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson), John Camm, Raffaele De Caterina, Veronica Dean, Kenneth Dickstein, Christian Funck-Brentano, Gerasimos Filippatos, Irene Hellemans, Steen Dalby Kristensen, Keith McGregor, Udo Sechtem, Sigmund Silber, Michal Tendera, Petr Widimsky, Jose Luis Zamorano

Document reviewers: Irene Hellemans (CPG Review Co-ordinator), Attila Altiner, Enzo Bonora, Paul N. Durrington, Robert Fagard, Simona Giampaoli, Harry Hemingway, Jan Hakansson, Sverre Erik Kjeldsen, Mogens Lytken Larsen, Giuseppe Mancia, Athanasios J. Manolis, Kristina Orth-Gomer, Terje Pedersen, Mike Rayner, Lars Ryden, Mario Sammut, Neil Schneiderman, Anton F. Stalenhoef, Lale Tokgözoglu, Olov Wiklund, Antonis Zampelas

Survival in relation to angina symptoms and diagnosis among men aged 70-90 years: the Whitehall Study

BACKGROUND

While the excess mortality associated with a diagnosis of angina, myocardial infarction in middle-aged individuals is well established, there is little available evidence on the natural history of angina in population-based studies of older people.

DESIGN

We conducted a 5-year follow-up of 6655 older men aged 67-90 years (mean age 77 years) who participated in the Whitehall Study of London Civil Servants.

METHODS

Survival was examined in relation to a diagnosis of angina or myocardial infarction and to angina symptoms in a population-based study of older men living in the United Kingdom in the late 1990s.

RESULTS

Compared with men without a diagnosis of myocardial ischaemia (n=5219), a diagnosis of angina alone (n=617), myocardial infarction alone (n=421) or both (n=398) were associated with about a threefold, fourfold and sixfold higher risk of death from coronary heart disease, respectively. Median expectation of life at age 70 years was reduced by about 2, 5 and 6 years for those with angina, myocardial infarction, or both, respectively. Current symptoms of angina among those without previously diagnosed angina, was associated with a 2-fold higher risk of coronary heart disease mortality than those without either diagnosis or symptoms.

CONCLUSIONS

Both angina symptoms and diagnosis have a significant adverse effect on survival among men aged 70-90 years highlighting the importance of diagnosis and appropriate treatment of angina in old age.

Increased sickness absence in diabetic employees: what is the role of co-morbid conditions?

AIMS

Diabetes is thought to be associated with increased risk of sickness absence in working populations. We examined the contribution of co-morbidity to this association.

METHODS

Records of physician-certified sickness absence episodes (> 3 days) over a 1-year period were obtained from employers' records after a survey of chronic diseases and risk factors in 638 diabetic and 32 510 non-diabetic public sector employees in Finland (the Public Sector Study).

RESULTS

Diabetic employees had a 2.15-fold (95% confidence interval 1.92-2.40) age- and sex-adjusted excess risk of sickness absence compared with their colleagues with no chronic disease. In absolute terms, diabetes was related to 59 extra absence episodes per 100 person years. Of this excess risk, 55% was attributable to co-occurring non-cardiovascular diseases, such as depression, prolapsed intervertebral disc and bronchitis. The contribution of cardiovascular complications to the excess sickness absence was small (7%).

CONCLUSIONS

In this occupational cohort, the excess risk of sickness absence in diabetic employees was largely accounted for by non-cardiovascular co-morbidity. Intervening multiple chronic conditions may be important in programmes to reduce sickness absence in diabetic employees.

Changes in heart rate and heart rate variability over time in middle-aged men and women in the general population (from the Whitehall II Cohort Study)

Previous cross-sectional studies have shown that heart rate (HR) and HR variability (HRV) are influenced by several behavioral, biologic, and psychosocial factors. There are very few longitudinal studies that enable analyses of changes in HRV over time at an individual level. This study aimed to describe changes in HR and HRV in a general population setting and to determine predictors of HR and HRV at follow-up. From 1997 to 2004, 1,999 participants (29% women) in the United Kingdom Whitehall II Cohort Study had 2 measurements of cardiac autonomic function (mean time between measurements 5.47 years, range 4.07 to 6.93). The mean +/- SD age at the first measurement was 55.6 +/- 6.0 years. At baseline, men showed higher low-frequency power than women, suggesting that they may have higher sympathetic activity. Conversely, women had higher high-frequency power, indicating higher parasympathetic tone. Over the 5-year follow-up period, men and women had decreases in HR. Men had reductions in HRV in time and frequency dimensions, whereas women showed increases in HRV. In conclusion, the probability of being in the adverse quartile of HRV function and HR at follow-up was related to baseline exercise, body mass index, cholesterol, and blood pressure.

Prognosis of stable angina pectoris: why we need larger population studies with higher endpoint resolution

The prognosis of angina was described as "unhappy" by the Framingham investigators and as little different from that of 1-year survivors of acute myocardial infarction. Yet recent clinical trials now report that angina has a good prognosis with adverse outcomes reduced to "normal levels". These disparate prognostic assessments may not be incompatible, applying as they do to population cohorts (Framingham) and selected participants in clinical trials. Comparisons between studies are further complicated by the absence of agreed case definitions for stable angina (contrast this with acute coronary syndromes). Our recent data show that for patients with recent onset symptoms attending chest pain clinics, angina remains a high-risk diagnosis and although many patients receive symptomatic benefit from revascularisation, prognosis is usually unaffected. This leaves little room for complacency and, with angina the commonest initial manifestation of coronary artery disease, there is the opportunity for early detection, risk stratification and treatment to modify outcomes. Meanwhile, larger population-based studies are needed to define the patient journey from earliest presentation through the various syndrome transitions to coronary or noncardiac death in order to increase understanding of the aetiological and prognostic differences between the different coronary disease phenotypes.

Epidemiology of angina pectoris: role of natural language processing of the medical record

BACKGROUND

The diagnosis of angina is challenging because 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 ascertainment over diagnostic codes.

METHODS

Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina.

RESULTS

Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P < .001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .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 a 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.

Mild to moderate renal impairment is associated with increased left ventricular mass

BACKGROUND

Mild to moderate renal impairment (MMRI) is associated with an excess cardiovascular mortality but the reason for this is unclear. Increased left ventricular mass (LVM) is associated with severe renal dysfunction and a higher cardiovascular mortality. However, whether increased LVM also occurs in patients with milder renal dysfunction is unknown.

METHODS

336 consecutive patients under investigation for chest pain who underwent concurrent coronary angiography, serum creatinine (Cr) and LVM assessment, were recruited from a university hospital in Shanghai, China. The main outcome measures were: LVM normalised for body surface area (NLVM), renal function determined by Cr, creatinine clearance (CrCl) (Cockroft-Gault equation) and glomerular filtration rate (GFR) (Modification of Diet in Renal Disease equation).

RESULTS

Mean+/-SD age was 56.8+/-9.5 years, 282 (84%) were male, mean NLVM 107.1+/-36.8 g/m(2), Cr 0.94+/-0.22 mg/dL, CrCl 82.7+/-21.7 mL/min/1.73 m(2) and GFR 89.4+/-24.6 mL/min/1.73 m(2). NLVM was related to Cr (r=-0.30), CrCl (r=0.19) and GFR (r=0.24) (all p<0.001). A multiple logistic regression model using quartile analysis of renal function showed that those patients with a Cr 1.06-2.00 mg/dL, CrCl 34.8-67.5 mL/min/1.73 m(2) and a GFR 36.2-73.4 mL/min/1.73 m(2) were significantly associated with increased NLVM, independent of other variables. Using definitions derived from the National Kidney Foundation Guidelines multiple regression analysis showed MMRI to be independently associated with increased NLVM: Cr 1.2-1.9 mg/dL, odds ratio (OR) 2.77 (CI 1.04-7.40) (p=0.04); CrCl 30-89.9 mL/min/1.73 m(2), OR 1.63 (CI 0.91-2.93) (p=0.11); GFR 30-89.9 mL/min/1.73 m(2), OR 1.76 (CI 1.07-2.90) (p=0.03).

CONCLUSION

In patients being investigated for chest pain, MMRI is significantly and independently associated with increased LVM.

Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study

OBJECTIVE

To assess whether revascularisation that is considered to be clinically appropriate is also cost effective.

DESIGN

Prospective observational study comparing cost effectiveness of coronary artery bypass grafting, percutaneous coronary intervention, or medical management within groups of patients rated as appropriate for revascularisation.

SETTING

Three tertiary care centres in London.

PARTICIPANTS

Consecutive, unselected patients rated as clinically appropriate (using a nine member Delphi panel) to receive coronary artery bypass grafting only (n=815); percutaneous coronary intervention only (n=385); or both revascularisation procedures (n=520).

MAIN OUTCOME MEASURE

Cost per quality adjusted life year gained over six year follow-up, calculated with a National Health Service cost perspective and discounted at 3.5%/year.

RESULTS

Coronary artery bypass grafting cost 22,000 pounds sterling (33,000 euros; $43,000) per quality adjusted life year gained compared with percutaneous coronary intervention among patients appropriate for coronary artery bypass grafting only (59% probability of being cost effective at a cost effectiveness threshold of 30,000 pounds sterling per quality adjusted life year) and 19,000 pounds sterling per quality adjusted life year gained compared with medical management among those appropriate for both types of revascularisation (probability of being cost effective 63%). In none of the three appropriateness groups was percutaneous coronary intervention cost effective at a threshold of 30,000 pounds sterling per quality adjusted life year. Among patients rated appropriate for percutaneous coronary intervention only, the cost per quality adjusted life year gained for percutaneous coronary intervention compared with medical management was 47,000, pounds sterling exceeding usual cost effectiveness thresholds; in these patients, medical management was most likely to be cost effective (probability 54%).

CONCLUSIONS

Among patients judged clinically appropriate for coronary revascularisation, coronary artery bypass grafting seemed cost effective but percutaneous coronary intervention did not. Cost effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention may not be sufficient to justify its cost.

Effect of Patient-Specific Ratings vs Conventional Guidelines on Investigation Decisions in Angina

BACKGROUND

Conventional guidelines have limited effect on changing physicians' test ordering. We sought to determine the effect of patient-specific ratings vs conventional guidelines on appropriate investigation of angina.

METHODS

Randomized controlled trial of 145 physicians receiving patient-specific ratings (online prompt stating whether the specific vignette was considered appropriate or inappropriate for investigation, with access to detailed information on how the ratings were derived) and 147 physicians receiving conventional guidelines from the American Heart Association and the European Society of Cardiology. Physicians made recommendations on 12 Web-based patient vignettes before and on 12 vignettes after these interventions. The outcome was the proportion of appropriate investigative decisions as defined by 2 independent expert panels.

RESULTS

Decisions for exercise electrocardiography were more appropriate with patient-specific ratings (819/1491 [55%]) compared with conventional guidelines (648/1488 [44%]) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.36-1.82). The effect was stronger for angiography (1274/1595 [80%] with patient-specific ratings compared with 1009/1576 [64%] with conventional guidelines [OR, 2.24; 95% CI, 1.90-2.62]). Within-arm comparisons confirmed that conventional guidelines had no effect but that patient-specific ratings significantly changed physicians' decisions toward appropriate recommendations for exercise electrocardiography (55% vs 42%; OR, 2.62; 95% CI, 2.14-3.22) and for angiography (80% vs 65%; OR, 2.10; 95% CI, 1.79-2.47). These effects were robust to physician specialty (cardiologists and general practitioners) and to vignette characteristics, including older age, female sex, and nonwhite race/ethnicity.

CONCLUSION

Patient-specific ratings, unlike conventional guidelines, changed physician testing behavior and have the potential to reduce practice variations and to increase the appropriate use of investigation.

Cardiothoracic ratio within the "normal" range independently predicts mortality in patients undergoing coronary angiography

OBJECTIVE

To determine whether cardiothoracic ratio (CTR), within the range conventionally considered normal, predicted prognosis in patients undergoing coronary angiography.

DESIGN

Cohort study with a median of 7-years follow-up.

SETTING

Consecutive patients undergoing coronary angiography at Barts and The London National Health Service (NHS) Trust.

SUBJECTS

1005 patients with CTRs measured by chest radiography, and who subsequently underwent coronary angiography. Of these patients, 7.3% had a CTR > or =0.5 and were excluded from the analyses.

OUTCOMES

All-cause mortality and coronary event (non-fatal myocardial infarction or coronary death). Adjustments were made for age, left ventricular dysfunction, ACE inhibitor treatment, body mass index, number of diseased coronary vessels and past coronary artery bypass graft.

RESULTS

The risk of death was increased among patients with a CTR in the upper part of the normal range. In total, 94 (18.9%) of those with a CTR below the median of 0.42 died compared with 120 (27.8%) of those with a CTR between 0.42 and 0.49 (log rank test p<0.001). After adjusting for potential confounders, this increased risk remained (adjusted HR 1.45, 95% CI 1.03 to 2.05). CTR, at values below 0.5, was linearly related to the risk of coronary event (test for trend p = 0.024).

CONCLUSION

In patients undergoing coronary angiography, CTR between 0.42 and 0.49 was associated with higher mortality than in patients with smaller hearts. There was evidence of a continuous increase in risk with higher CTR. These findings, along with those in healthy populations, question the conventional textbook cut-off point of > or =0.5 being an abnormal CTR.

Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies

AIMS

With negative treatment trials, the role of depression as an aetiological or prognostic factor in coronary heart disease (CHD) remains controversial. We quantified the effect of depression on CHD, assessing the extent of confounding by coronary risk factors and disease severity.

METHODS AND RESULTS

Meta-analysis of cohort studies measuring depression with follow-up for fatal CHD/incident myocardial infarction (aetiological) or all-cause mortality/fatal CHD (prognostic). We searched MEDLINE and Science Citation Index until December 2003. In 21 aetiological studies, the pooled relative risk of future CHD associated with depression was 1.81 (95% CI 1.53-2.15). Adjusted results were included for 11 studies, with adjustment reducing the crude effect marginally from 2.08 (1.69-2.55) to 1.90 (1.49-2.42). In 34 prognostic studies, the pooled relative risk was 1.80 (1.50-2.15). Results adjusted for left ventricular function result were available in only eight studies; and this attenuated the relative risk from 2.18 to 1.53 (1.11-2.10), a 48% reduction. Both aetiological and prognostic studies without adjusted results had lower unadjusted effect sizes than studies from which adjusted results were included (P<0.01).

CONCLUSION

Depression has yet to be established as an independent risk factor for CHD because of incomplete and biased availability of adjustment for conventional risk factors and severity of coronary disease.

How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients

OBJECTIVE

To determine whether rapid access chest pain clinics are clinically effective by comparison of coronary event rates in patients diagnosed with angina with rates in patients diagnosed with non-cardiac chest pain and the general population.

DESIGN

Multicentre cohort study of consecutive patients with chest pain attending the rapid access chest pain clinics (RACPCs) of six hospitals in England.

PARTICIPANTS

8762 patients diagnosed with either non-cardiac chest pain (n = 6396) or incident angina without prior myocardial infarction (n = 2366) at first cardiological assessment, followed up for a median of 2.57 (interquartile range 1.96-4.15) years.

MAIN OUTCOME MEASURES

Primary end point--death due to coronary heart disease (International Classification of Diseases (ICD)10 I20-I25) or acute coronary syndrome (non-fatal myocardial infarction (ICD10 I21-I23), hospital admission with unstable angina (I24.0, I24.8, I24.9)). Secondary end points--all-cause mortality (ICD I20), cardiovascular death (ICD10 I00-I99), or non-fatal myocardial infarction or non-fatal stroke (I60-I69).

RESULTS

The cumulative probability of the primary end point in patients diagnosed with angina was 16.52% (95% confidence interval (CI) 14.88% to 18.32%) after 3 years compared with 2.73% (95% CI 2.29% to 3.25%) in patients with non-cardiac chest pain. Coronary standardised mortality ratios for men and women with angina aged <65 years were 3.52 (95% CI 1.98 to 5.07) and 4.39 (95% CI 1.14 to 7.64). Of the 599 patients who had the primary end point, 194 (32.4%) had been diagnosed with non-cardiac chest pain. These patients were younger, less likely to have typical symptoms, more likely to be south Asian and more likely to have a normal resting electrocardiogram than patients with angina who had the primary end point.

CONCLUSION

RACPCs are successful in identifying patients with incident angina who are at high coronary risk, but there is a need to reduce misdiagnosis and improve outcomes in patients diagnosed with non-cardiac chest pain who accounted for nearly one third of cardiac events during follow-up.

Prognosis research: why is Dr. Lydgate still waiting?

BACKGROUND

Understanding prognosis--the future risk of adverse outcomes among people with existing disease--plays third fiddle behind clinical research into therapeutic interventions and novel diagnostic technologies.

METHODS AND RESULTS

Diseases show marked variations in a wide range of prognostic outcomes, yet these variations have seldom been the subject of systematic and sustained epidemiologic and multidisciplinary research. This is important to prioritize hypotheses for testing in intervention studies in groups, and to refine tools for prognostication in individuals. Methodologic standards for the design, conduct, analysis and reporting of prognosis research are required. Training is needed for the clinicians, policymakers, and payers who use prognostic information.

CONCLUSION

Here, arguments detracting from the potential scope of prognosis research are rebutted and misconceptions addressed with the aim of stimulating debate on the evolving role of prognosis research.

Appropriateness of VATS and bedside thoracostomy talc pleurodesis as judged by a panel using the RAND/UCLA appropriateness method (RAM)

We sought formal consensus on the appropriateness of Video-assisted Thoracoscopic Surgery (VATS) talc pleurodesis and bedside thoracostomy talc slurry by use of a well established method - the RAND/UCLA appropriateness method (RAM). We recruited an expert panel of respiratory physicians, oncologists, and surgeons under the leadership of experts in health services research. The panellists were provided with evidence from a systematic review and then were taken through two rounds of opinion gathering, the first individually, the second as a group. The purpose is not to force consensus, but to find scenarios where there is agreement on the appropriateness or inappropriateness of a treatment and scenarios where there is disagreement. In scenarios where the diagnosis was proven and expectation of life beyond six months, pleurodesis was deemed appropriate. If there was no tissue diagnosis surgical VATS was preferred. The response to a trial aspiration played a major part in the recommendation for or against pleurodesis. The attitude to breathlessness was incongruous; it is the target of palliation yet some interpreted it as performance status and thus a contraindication. Although the RAM is well developed and in widespread use, we found it worryingly unreliable and to be used with caution.

Incidence and prognostic implications of stable angina pectoris among women and men

CONTEXT

Stable angina pectoris in women has often been considered a "soft" diagnosis, with less-severe prognostic implications than in men, but large-scale population studies are lacking.

OBJECTIVE

To determine sex differences in the incidence and prognosis of stable angina in a large ambulatory population.

DESIGN

Prospective cohort study using linked national registers.

SETTING

All municipal primary health care centers, hospital outpatient clinics, occupational health care services, and the private sector in Finland.

PARTICIPANTS

Among ambulatory patients aged 45 to 89 years who had no history of coronary disease, we defined new cases of "nitrate angina" based on nitrate prescription (56,441 women and 34,885 men) or "test-positive angina" based on abnormal invasive or noninvasive test results (11,391 women and 15,806 men). Potentially eligible patients were evaluated between January 1, 1996, and December 31, 1998. Follow-up ended in December 2001.

MAIN OUTCOME MEASURES

Coronary mortality at 4 years (n = 7906 deaths) and fatal and nonfatal myocardial infarction at 1 year (n = 3129 events).

RESULTS

The age-standardized annual incidence per 100 population of all cases of angina was 2.03 in men and 1.89 in women, with a sex ratio of 1.07 (95% confidence interval [CI], 1.06-1.09). At every age, nitrate angina in women and men was associated with a similar increase in risk of coronary mortality relative to the general population. Women with test-positive angina who were younger than 75 years had higher coronary-standardized mortality ratios than men; for example, among those aged 55 to 64 years, it was 4.69 (95% CI, 3.60-6.11) in women compared with 2.40 (95% CI, 2.11-2.73) in men (P<.001 for interaction). There was a strong, graded relationship between amount of nitrates used and event rates; women using higher doses of nitrates had prognoses comparable with those of men. Among patients with diabetes and test-positive angina, age-standardized coronary event rates were 9.9 per 100 person-years in women vs 9.3 in men (P = .69), and the fully adjusted male-female sex ratio was 1.07 (95% CI, 0.81-1.41).

CONCLUSIONS

Women have a similarly high incidence of stable angina compared with men. Furthermore, stable angina in women is associated with increased coronary mortality relative to women in the general population and, among easily identifiable clinical subgroups, has similarly high absolute rates of prognostic outcomes compared with men.