Comparison of a supplemented Rose Questionnaire to exercise thallium testing in men and women

Previously undiagnosed angina pectoris in individuals without established cardiovascular disease: Prevalence and prognosis in the United States

BACKGROUND

The prevalence and prognosis of previously undiagnosed angina pectoris (AP) in the absence of established cardiovascular disease (CVD) are unknown. This study sought to determine the prevalence and prognosis of previously undiagnosed AP in the absence of established CVD in the United States.

METHODS

Data derived from the National Health and Nutrition Examination Survey (2001-2018) and the Rose Angina Questionnaire (RAQ) were used to identify AP among participants ≥ 40 years without established CVD. Determinants of previously undiagnosed AP (AP undiagnosed prior to RAQ analysis) and predictors of all-cause mortality were identified using multivariable logistic regression analysis and the Cox proportional hazard model.

RESULTS

Of the 27,506 participants eligible for analysis, 621 participants had previously undiagnosed AP. Thus, the prevalence of previously undiagnosed AP was 1.99% (95% CI 1.79-2.20). Female gender, poverty, < high school education, hypertension, cigarette smoking, and obesity were independent predictors of previously undiagnosed AP. All-cause mortality rates were 1.71 per 1000 person months for participants with previously undiagnosed AP and were 1.08 per 1000 person months to those without previously undiagnosed AP (p = 0.003).

CONCLUSIONS

The prevalence of previously undiagnosed AP in the United States is 1.99% in persons ≥ 40 years of age without established CVD. Previously undiagnosed AP in those without established CVD was an independent predictor of all-cause mortality.

The Gender Perspective Within the OFRECE Study: Differences in Health Care Among Patients Consulting for Chest Pain and/or Palpitations

INTRODUCTION AND OBJECTIVES

To analyze differences between sexes in the clinical management of patients presenting with symptoms of chest pain and/or palpitations within a population-based study.

METHODS

The OFRECE study included a random sample of 8400 individuals from the Spanish population aged 40 years and older; 1132 (13.5%) had previously consulted for chest pain and 1267 (15.1%) had consulted for palpitations and were included in the present study. We calculated both the crude and adjusted odds ratios (OR) of undergoing certain tests and the results of consultations by sex. Adjustment was performed by classic cardiovascular risk factors, a personal history of cardiovascular disease, and a diagnosis of stable angina or atrial fibrillation confirmed in the OFRECE study in each case.

RESULTS

No differences were observed in history of consultation for chest pain between women and men (13% vs 14.1%; P=.159) but differences were found in palpitations (19% vs 10.4%, respectively; P <.001). Women who had previously consulted for chest pain underwent fewer echocardiograms (32.5% vs 45.3%, respectively; P <.001), were less frequently referred to a cardiologist (49.1% vs 60.1%; P <.001), were less often admitted to hospital (20.1% vs 39.4%; P <.001), and less frequently received a confirmed diagnosis (60.9 vs 71, 9; P <.001). After full adjustment, all differences decreased and become nonsignificant echocardiograms: adjusted OR, 0.81; 95%CI, 0.60-1.09; referral to a cardiologist: adjusted OR, 0.86; 95%CI, 0.63-1.16; hospital admission: adjusted OR, 0.76; 95%CI, 0.54-1.09). For palpitations, crude differences were smaller and all became nonsignificant after adjustment.

CONCLUSIONS

This study does not confirm the existence of sex-related bias in the management of chest pain and palpitations. However, such bias cannot be completely ruled out in diagnoses confirmed within the OFRECE study, which might limit its ability to detect sex-related differences in health care.

The prevalence of familial hypercholesterolemia in the West Siberian region of the Russian Federation: A substudy of the ESSE-RF

Background

The prevalence of familial hypercholesterolemia (FH) in Russia has not previously been evaluated. The aim of our study was to investigate the prevalence of FH in the population of the West Siberian region of Russia, and then estimate the frequency of coronary artery disease (CAD) and treatment with cholesterol-lowering medication in FH patients.

Methods

The sample of our study consisted of participants from the population-based cohort of The Epidemiology of Cardiovascular Risk Factors and Diseases in Regions of the Russian Federation Study (ESSE-RF), conducted in the Tyumen and Kemerovo regions (1,630 and 1,622 people, respectively, aged 25–64). All participants who had LDL-cholesterol higher than 4.9 mmol/l and who had LDL-cholesterol less than or equal to 4.9 mmol/l but had statin therapy were examined and interviewed by experts in FH.

Results

The prevalence of patients with definite FH was 0.24% (one in 407) (95% confidence interval [CI]: 0.06%–0.42%), with probable FH was 0.68% (one in 148) (95% CI: 0.38%–0.98%), and with definite or probable FH combined was 0.92% (one in 108) (95% CI: 0.58%–1.26%). 40% (95% CI: 20.8%–59.2%) of patients with definite or probable FH had CAD. However, only 23% (95% CI: 6.3%–39.7%) of patients with definite or probable FH were on statins. The odds ratios for CAD and myocardial infarction (MI), adjusted for age, gender, region, smoking, hypertension, and diabetes mellitus, were 3.71 (95% CI: 1.58–8.72) (p = 0.003) and 4.06 (95% CI: 0.89–18.55) (р = 0.070) respectively for individuals with definite or probable FH relative to those who were unlikely to have FH.

Conclusions

The prevalence of FH in Russia may be significantly higher than previously estimated. There is underdiagnosis and undertreatment of FH in Russia.

The global burden of ischemic heart disease in 1990 and 2010: the Global Burden of Disease 2010 study

BACKGROUND

Ischemic heart disease (IHD) burden consists of years of life lost from IHD deaths and years of disability lived with 3 nonfatal IHD sequelae: nonfatal acute myocardial infarction, angina pectoris, and ischemic heart failure. Our aim was to estimate the global and regional burden of IHD in 1990 and 2010.

METHODS AND RESULTS

Global and regional estimates of acute myocardial infarction incidence and angina and heart failure prevalence by age, sex, and world region in 1990 and 2010 were estimated based on data from a systematic review and nonlinear mixed-effects meta-regression methods. Age-standardized acute myocardial infarction incidence and angina prevalence decreased globally between 1990 and 2010; ischemic heart failure prevalence increased slightly. The global burden of IHD increased by 29 million disability-adjusted life-years (29% increase) between 1990 and 2010. About 32.4% of the growth in global IHD disability-adjusted life-years between 1990 and 2010 was attributable to aging of the world population, 22.1% was attributable to population growth, and total disability-adjusted life-years were attenuated by a 25.3% decrease in per capita IHD burden (decreased rate). The number of people living with nonfatal IHD increased more than the number of IHD deaths since 1990, but >90% of IHD disability-adjusted life-years in 2010 were attributable to IHD deaths.

CONCLUSIONS

Globally, age-standardized acute myocardial infarction incidence and angina prevalence have decreased, and ischemic heart failure prevalence has increased since 1990. Despite decreased age-standardized fatal and nonfatal IHD in most regions since 1990, population growth and aging led to a higher global burden of IHD in 2010.

Door-to-door survey of cardiovascular health, stroke, and ischemic heart disease in rural coastal Ecuador--the Atahualpa Project: methodology and operational definitions

RATIONALE

Stroke and cardiovascular diseases will be the next health epidemics in Latin America due to increased life expectancy and changes in the lifestyle and dietary habits of the population. Knowledge of the cardiovascular health status of the inhabitants will allow the implementation of policies directed to reduce the burden of stroke and cardiovascular diseases in the region.

AIMS

To evaluate the cardiovascular health status of the inhabitants of Atahualpa (a rural village in coastal Ecuador) and to determine the prevalence and incidence of stroke and ischemic heart disease in the region.

DESIGN

Three-phase epidemiologic survey. During phase I, Atahualpa residents aged ≥40 years will be screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In phase II, neurologists and cardiologists will examine suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess the prevalence and incidence of these conditions. In phase III, patients with a diagnosis of stroke and ischemic heart disease will undergo complementary tests for achieving a more specific diagnosis.

DISCUSSION

Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective in improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations.

Assessing the Global Burden of Ischemic Heart Disease: Part 1: Methods for a Systematic Review of the Global Epidemiology of Ischemic Heart Disease in 1990 and 2010

BACKGROUND

Ischemic heart disease (IHD) is the leading cause of death worldwide. The GBD (Global Burden of Disease, Injuries, and Risk Factors) study (GBD 2010 Study) conducted a systematic review of IHD epidemiology literature from 1980 to 2008 to inform estimates of the burden on IHD in 21 world regions in 1990 and 2010.

METHODS

The disease model of IHD for the GBD 2010 Study included IHD death and 3 sequelae: myocardial infarction, heart failure, and angina pectoris. Medline, EMBASE, and LILACS were searched for IHD epidemiology studies in GBD high-income and low- and middle-income regions published between 1980 and 2008 using a systematic protocol validated by regional IHD experts. Data from included studies were supplemented with unpublished data from selected high-quality surveillance and survey studies. The epidemiologic parameters of interest were incidence, prevalence, case fatality, and mortality.

RESULTS

Literature searches yielded 40,205 unique papers, of which 1,801 met initial screening criteria. Upon detailed review of full text papers, 137 published studies were included. Unpublished data were obtained from 24 additional studies. Data were sufficient for high-income regions, but missing or sparse in many low- and middle-income regions, particularly Sub-Saharan Africa.

CONCLUSIONS

A systematic review for the GBD 2010 Study provided IHD epidemiology estimates for most world regions, but highlighted the lack of information about IHD in Sub-Saharan Africa and other low-income regions. More complete knowledge of the global burden of IHD will require improved IHD surveillance programs in all world regions.

Low education as a risk factor for undiagnosed angina

BACKGROUND

Early awareness, recognition, and treatment of angina can help prevent or delay an acute myocardial infarction and potentially delay death. A patient's educational level may affect a physician's diagnosis of angina and/or a patient's symptom recognition. The objective of this study was to determine whether low education is a risk factor for undiagnosed angina.

METHODS

This was a cross-sectional observational study based on data from the National Health and Nutrition Examination Survey 2001 to 2008, providing a nationally representative sample of adults ≥40 years of age with angina based on physician diagnosis, presence of angina symptoms based on the Rose Questionnaire, or both. Educational attainment (high school or less vs more than high school) was the independent variable of interest. Undiagnosed angina (angina symptoms in the absence of angina diagnosis) was the dependent variable. We used logistic regression to control for age, sex, race/ethnicity, income, and health care visit during the past year.

RESULTS

Low education was associated with undiagnosed angina (odds ratio: 1.43; 95% confidence interval: 1.01-2.03). Other undiagnosed angina predictors included being female, being black, and having no health care visit during the past year.

CONCLUSIONS

Low education is associated with undiagnosed angina. These results underscore the need for providers to ask about angina symptoms and confirm patients' understanding of their angina diagnosis among those with low education.

Angina and intermittent claudication in 7403 participants of the 2003 Scottish Health Survey: impact on general and mental health, quality of life and five-year mortality

BACKGROUND

Angina and intermittent claudication impair function and mobility and reduce health-related quality of life. Both symptoms have similar etiology, yet the physical and psychological impacts of these symptoms are rarely studied in community-based cohorts or in individuals with isolated symptoms.

METHODS

The 2003 Scottish Health Survey was a cross-sectional survey which enrolled a random sample of individuals aged 16-95 years living in Scotland. The Rose Angina Questionnaire, the Edinburgh Claudication Questionnaire, the Short Form-12 (SF-12) and the General Health Questionnaire were completed. Self-assessed general health was reported. Survey results were linked to national death records and mortality at five years was calculated. Subjects with isolated angina or intermittent claudication and neither symptom were compared (22 participants with both symptoms were excluded); 7403 participants (aged ≥ 16 years) were included.

RESULTS

Participants with angina (n=205; 60 ± 15 years; 45% male) rated their general health worse and were more likely to have a potential mental-health problem than those with intermittent claudication (n=173; 61 ± 15 years; 41% male). Mean (standard deviation) physical and mental component scores on the SF-12 were higher for participants with intermittent claudication relative to those with angina (physical component score: 42.3 (10.6) vs. 35.0 (11.7), p<0.001; mental component score: 52.3 (8.5) vs. 46.5 (11.7), p=0.001). There was an observed absolute difference in five-year mortality of 4.8% (angina 12.3%, 95% CI 8.5-17.6; intermittent claudication 7.5%, 95% CI 4.4-12.6) although not statistically significant (p=0.16).

CONCLUSIONS

Both intermittent claudication and angina adversely impact general and mental health and survival, even in a relatively young, community-based cohort.

Symptom clusters and health-related quality of life in people with chronic stable angina

AIM

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

BACKGROUND

People 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 people with chronic angina.

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, dyspnoea and quality of life. The data have contemporary relevance because despite changes in treatment of coronary heart disease, chronic angina remains prevalent worldwide. Hierarchical multiple linear regression was used to examine the symptom cluster of chest pain frequency, fatigue and dyspnoea in predicting quality of life.

RESULTS

The sample was predominantly white (74·6%), men (59·7%) with a mean age of 63·4 (sd 12·12) years. Controlling for age, gender, social status and co-morbidities, the symptom cluster of chest pain frequency, dyspnoea and fatigue accounted for a statistically significant increase in unadjusted R² (F of Δ, P < 0·05) 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 people 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.

The Iranian version of Angina Pectoris characteristics questionnaire: reliability assessment

AIMS

To evaluate internal consistency and test-retest reliability of the Iranian version of the Angina Pectoris characteristics questionnaire.

BACKGROUND

To evaluate symptoms in patients with Angina Pectoris, the Iranian version of the Angina Pectoris characteristics questionnaire was created by combining items from Modified Rose Questionnaire, Short Form-McGill Questionnaire and the Accompanying Symptom Checklist. The Angina Pectoris characteristics questionnaire has been developed and validated recently although it required assessment of its reliability.

DESIGN

Reliability study using test and retest.

METHOD

One hundred and ten coronary heart disease patients with Angina Pectoris were included. The test-retest reliability of the instrument was estimated for measurement after 15 days.

RESULT

The analysis of the result indicated that internal consistency was found adequate at both assessments (Cronbach's alpha = 0.65) for test and retest. There was no significant difference between test and retest. The intra-class correlation coefficient ranged from 0.76-0.98.

CONCLUSION

The Angina Pectoris characteristics questionnaire is a reliable instrument for the assessment of Angina Pectoris characteristics in a Persian population.

RELEVANCE TO CLINICAL PRACTICE

The Angina Pectoris characteristics questionnaire can be used with confidence in Iranian coronary heart disease patients for Assessing Angina Pectoris symptom.

A population study of the long-term consequences of Rose angina: 20-year follow-up of the Renfrew-Paisley study

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.

Prevalence, incidence, primary care burden and medical treatment of angina in Scotland: age, sex and socioeconomic disparities: a population-based study

OBJECTIVE

To examine the epidemiology, primary care burden and treatment of angina in Scotland.

DESIGN

Cross-sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 2001 and 31 March 2002.

SETTING

55 primary care practices (362 155 patients).

PARTICIPANTS

9508 patients with angina.

RESULTS

The prevalence of angina in Scotland was 28/1000 in men and 25/1000 in women (p < 0.05) and increased with age. The prevalence of angina also increased with increasing socioeconomic deprivation from 18/1000 in the least deprived category to 31/1000 in the most deprived group (p < 0.001 for trend). The incidence of angina was higher in men (1.8/1000) than in women (1.4/1000) (p = 0.004) and increased with increasing age and socioeconomic deprivation. Socioeconomically deprived patients (0.48 contacts/patient among the most deprived) were less likely than affluent patients (0.58 contacts/patient among the least deprived) to see their general practitioner on an ongoing basis p = 0.006 for trend). Among men, 52% were prescribed beta blockers, 44% calcium channel blockers, 72% aspirin, 54% statins and 36% angiotensin converting enzyme inhibitors or angiotensin receptor blockers. The corresponding prescription rates for women were 46% (p < 0.001), 41% (p = 0.02), 69% (p < 0.001), 45% (p < 0.001) and 30% (p < 0.001). Among patients < 75 years old 52% were prescribed a beta blocker and 58% a statin. The corresponding figures for patients >or= 75 years were 42% (p < 0.001) and 31% (p < 0.001).

CONCLUSIONS

Angina is a common condition, more so in men than in women. Socioeconomically deprived patients are more likely to have angina but are less likely to consult their general practitioner. Guideline-recommended treatments for angina are underused in women and older patients. These suboptimal practice patterns, which are worst in older women, are of particular concern, as in Scotland more women (and particularly older women) than men have angina.

Observer reproducibility and validity of systems for clinical classification of angina pectoris: comparison with radionuclide imaging and coronary angiography

OBJECTIVE

To assess reproducibility and validity of clinical classification of angina pectoris (AP) patients.

DESIGN

Fifty-six patients scheduled for coronary angiography because of stable AP were classified by two independent observers with regard to (i) type and (ii) severity of chest pain (Canadian Cardiovascular Society, CCS) and (iii) cardiac functional status (New York Heart Association, NYHA). Myocardial perfusion imaging (MPI) was performed in 55 including measurement of ejection fraction in 46, angiography was undertaken in 51.

RESULTS

Observers agreed 100% on the presence (n = 45) or absence (n = 11) of angina. They agreed in 52 (93%), 48 (86%), and 42 (75%) patients with regard to type of pain, CCS grade, and NYHA class, respectively. In the remaining patients, they disagreed by one class only. The positive and negative predictive values of typical/atypical angina for perfusion abnormalities and coronary disease were 55%/82% and 53%/ 82%, respectively.

CONCLUSIONS

Observer agreement was excellent for presence, type, and severity of chest pain but moderate with regard NYHA class. Clinical judgment could not predict with reasonable accuracy abnormal perfusion or coronary artery disease.

Migraine and other headaches: associations with Rose angina and coronary heart disease

OBJECTIVE

To examine the association between a lifetime history of migraines and other headaches with and without aura and Rose angina and coronary heart disease (CHD).

METHODS

Participants were 12,409 African American and white men and women from the Atherosclerosis Risk in Communities Study, categorized by their lifetime history of headaches lasting > or =4 hours (migraine with aura, migraine without aura, other headaches with aura, other headaches without aura, no headaches). Gender-specific associations of headaches with Rose angina and CHD, adjusted for sociodemographic and cardiovascular disease risk factors, were evaluated using Poisson regression.

RESULTS

Participants with a history of migraines and other headaches were more likely to have a history of Rose angina than those without headaches. The associations were stronger for migraine and other headaches with aura (prevalence ratio [PR] = 3.0, 95% CI = 2.4, 3.7 and PR = 2.0, 95% CI = 1.5, 2.7 for women; PR = 2.2, 95% CI = 1.2, 3.9 and PR = 2.4, 95% CI = 1.4, 3.9 for men) than for migraine and other headaches without aura (PR = 1.5, 95% CI = 1.2, 1.9 and PR = 1.3, 95% CI = 1.1, 1.6 for women; PR = 1.9, 95% CI = 1.2, 2.9 and OR = 1.4, 95% CI = 1.0, 1.8 for men). In contrast, migraine and other headaches were not associated with CHD, regardless of the presence of aura.

CONCLUSIONS

The lack of association of migraines with coronary heart disease suggests that the association of migraine with Rose angina is not related to coronary artery disease. Future research assessing other common underlying pathologic mechanisms is warranted.

Symptoms of peripheral arterial disease: A critical review

Peripheral arterial disease (PAD) is an atherosclerotic disease that leads to a narrowing of the arteries in the legs. This narrowing limits the amount of blood able to pass through the arteries. PAD is associated with significant morbidity and mortality, contributes to functional impairment, and can negatively impact quality of life. Claudication, the primary symptom of PAD, arises during activity when the blood and oxygen demand of the working skeletal muscle exceeds supply. The prevalence of claudication in patients with PAD varied from 4.5% to 54.4% in the articles reviewed. Variables that make understanding the symptom experience of PAD difficult include the type of population that research studies target, the wide range of definitions of claudication, and the lack of clear definitions regarding those who experience atypical symptoms or who are asymptomatic. This article reviews the literature related to the assessment, functional impairment, and symptom experience of patients with PAD, including a critique of the methods and findings of these studies. Education of health care professionals and the general public on what is known about PAD functional impairment and the symptom experience is greatly needed. Further research is needed. It is recommended to begin with qualitative research, which could then be used to improve quantitative assessments in those suspected of having PAD.

Possible angina detected by the WHO angina questionnaire in apparently healthy men with a normal exercise ECG: coronary heart disease or not? A 26 year follow up study

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.

Heart-focused anxiety and chest pain in postangiography medical patients

The present cross-sectional study sought to examine the extent to which heart-focused anxiety is associated with the co-occurrence of coronary artery disease (CAD) and a history of regular smoking in a sample of 148 postangiography patients from a cardiology unit. Individuals with CAD who regularly smoked demonstrated significantly greater heart-focused attention, but no greater degree of avoidance and fear of heart-focused sensations, than did nonsmoking persons with CAD and smokers without CAD. We also found evidence that heart-focused attention and fear incrementally predicted (above and beyond demographic variables and body mass index) intensity of average chest pain. Overall, this study provides some of the first empirical evidence that the occurrence of regular smoking and CAD is associated with specific dimensions of health anxiety. We discuss these findings in relation to models of panic pathology and anxious responding to bodily sensations.

Gender differences in pain characteristics of chronic stable angina and perceived physical limitation in patients with coronary artery disease

Chronic stable angina pectoris, the chest pain associated with reversible myocardial ischemia has detrimental effects on health-related quality of life, particularly in women. The limited research on gender differences in chronic stable angina suggests that angina may be experienced differently in women and that women report greater functional disability related to angina symptoms. No studies have examined gender differences in chronic stable angina from a multidimensional pain perspective or have included reliable and valid measures of pain that would facilitate comparing chronic angina patients with other chronic pain populations. The purpose of this descriptive study was to examine gender differences in characteristics of chronic stable angina using the short-form McGill pain questionnaire (SF-MPQ) and to explore relationships among these pain characteristics and perceived limitation in performing physical activities in patients with coronary artery disease (CAD) (physical limitation subscale of the Seattle angina questionnaire). One hundred and twenty-eight subjects (30.5% women) with stable CAD and angina pectoris documented by a cardiologist completed study questionnaires in an outpatient cardiology clinic. Results of the study suggest that men and women with chronic stable angina had more similarities than differences in chest pain characteristics. No significant gender differences were demonstrated in total sensory or affective intensity scores, the present pain intensity index, or the number of pain words chosen. However, women did report significantly greater pain intensity on the SF-MPQ visual analogue scale. Women were also significantly more likely to describe their chronic angina as 'hot-burning' and 'tender' and to have greater intensity of pain for these two descriptors. Despite the similarities in pain characteristics, women reported greater physical limitation related to anginal pain. The variables of social status and years diagnosed with CAD significantly interacted with gender in predicting physical limitation suggesting that gender-specific models of physical limitation in angina patients need to be explored. To our knowledge, this is one of the first studies that has assessed chronic anginal pain using a reliable and valid generic pain instrument. More research is needed to better understand the nature of gender differences in functional limitation secondary to anginal pain and the physiologic, cognitive-perceptual and psychosocial mechanisms that lead to angina-related functional disability.

Gender and noninvasive diagnosis of coronary artery disease in women and men

OBJECTIVES

The purpose of this prospective study was to investigate the impact of the gender of physicians and patients on the accuracy of diagnosing coronary artery disease (CAD) based on the patient history only.

METHODS

Screening involved 1082 consecutive patients undergoing coronary angiography for suspected CAD. Known CAD was an exclusion criterion. The inclusion criteria were met by 144 patients (47 females). All patients were inverviewed by both an experienced male cardiologist (n=6) and an experienced female cardiologist (n=5), who had to state before coronary angiography if CAD was present relying solely on the patient interview. Eligible subjects also answered a questionnaire. Diagnostic performance to assess the presence or absence of CAD by history taking by male and female cardiologists, exercise testing, patient self-assessment, and the questionnaire were compared.

RESULTS

Coronary angiography showed significant CAD in 20 females (43%) and 70 males (72%). Diagnostic accuracy was not different between male (79%) and female (79%) cardiologists and comparable to the results of exercise testing (74%) but better than self-assessment by the patients (65%, p=0.01) or a questionnaire (68%, p=0.01). The accuracy of female physicians was better in men than in women (85% vs. 66%, p=0.01). The specificity of male physicians tended to be better in women than in men (74% vs. 59%, p=0.25). Female cardiologists overestimated the presence of CAD in women (specificity 48% vs. 74%, p=0.04).

CONCLUSIONS

The female cardiologists did not assess women more accurately than did their male colleagues. The diagnostic accuracy of these male and female cardiologists was quite good. However, both tend to assess patients of the opposite gender more specifically. There may be an impact of the gender of the physician on the accuracy of diagnosis of CAD by history taking.

Sex differences in the association between proinsulin and intact insulin with coronary heart disease in nondiabetic older adults: the Rancho Bernardo Study

BACKGROUND

Insulin or insulin resistance is considered a coronary heart disease (CHD) risk factor, but proinsulin may have a stronger association with CHD than insulin. The role of sex differences in this association is unclear. We examined the cross-sectional association of proinsulin and insulin with CHD in older men and women without diabetes.

METHODS AND RESULTS

A cross-sectional study of community-dwelling men (n=554) and women (n=902), 50 to 97 years of age, without diabetes by history or oral glucose tolerance test, was done between 1992 and 1996; plasma levels of intact insulin, proinsulin, and C-peptide were measured by radioimmunoassay. Based on questionnaire, medical history, or ECG abnormalities, 25% of men (n=136) and 24% of women (n=214) had prevalent CHD. All insulin variables were positively correlated with CHD risk factors. Compared with those without CHD, men and women with CHD had significantly higher levels of proinsulin. Women but not men with CHD also had higher levels of C-peptide and fasting and postchallenge insulin. Only proinsulin was significantly and independently associated with prevalent CHD in both men (OR=2.41, 1.42 to 4.11) and women (OR=1.80, 1.22 to 2.64) (adjusted for age, body mass index, systolic blood pressure, and HDL cholesterol). Similar analyses for fasting and postchallenge intact insulin and for C-peptide showed that among these three variables, only postchallenge insulin was significantly associated with CHD, and only in women.

CONCLUSIONS

In older nondiabetic men and women, proinsulin was more strongly and consistently associated with CHD than was intact insulin.

The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK

BACKGROUND

The Rose angina questionnaire has been extensively used in different cultural settings, but may not perform consistently in different ethnic groups. We set out to assess the performance of the Rose angina questionnaire in UK South Asians compared with Europeans.

METHODS

Data on major ECG abnormalities, possible or definite Rose questionnaire angina and diagnosed angina were collected from an age- and sex-stratified random sample of 1509 adults from European, Indian, Pakistani and Bangladeshi ethnic groups.

RESULTS

The ECG abnormalities were commoner in South Asians than Europeans (6% versus 2% in men). The prevalence in both South Asian and European men of possible Rose angina and diagnosed angina was 18% and 8%, respectively, but definite Rose angina was less common in South Asians (3% versus 6%). Definite Rose angina showed lower sensitivity for other measures in South Asians than in Europeans: sensitivity for a doctor's diagnosis was 21% in South Asian and 37% in European men. For possible Rose angina, the corresponding figures were 81% and 84%. Similar patterns were seen in women.

CONCLUSIONS

The performance of the Rose angina questionnaire was sufficiently inconsistent to warrant further work to achieve greater cross-cultural validity. Possible Rose angina performed more consistently across ethnic groups than definite Rose angina and pending further validation studies may be the most appropriate form to use.

Cardiac instrument development in a low-literacy population: the revised Chest Discomfort Diary

OBJECTIVE

The purpose of this study was to pilot test a self-administered chest pain questionnaire, a revised version of the Chest Discomfort Diary (CDD-R), in a sample of patients with chronic angina selected from a population known to have low literacy.

DESIGN

The study design was descriptive and correlational.

SAMPLE

The study used a convenience sample of 27 subjects with documented history of coronary artery disease and angina. Characteristics of the sample included a mean age of 56.3 years (SD, 12.4 years), 88.9% African-American, and 56.3% male, and 59.3% had a history of acute myocardial infarction. Approximately 28% had achieved a 9th-grade education or less, and reading levels ranged from 4th grade to 12th grade. Subjects completed the CDD-R, a 36-item instrument reflecting multiple dimensions of anginal chest pain.

RESULTS

Descriptions of the location (left chest, 66.6%), character (pressure, 59.2%), and precipitants of chest pain (walking, 51.8%) were consistent with clinical descriptions of "typical angina." Other physical symptoms such as shortness of breath (88.8%) and fatigue (85.1%) were reported. Walking (55.5%) was the activity most frequently described as difficult to perform because of chest pain, with sublingual nitroglycerin (77.7%) the most frequently used and most effective chest pain relief strategy.

CONCLUSION

The CDD-R adequately measured multiple characteristics of anginal chest pain. Further research is needed to establish construct validity of the CDD-R and to determine the feasibility of using the instrument to monitor changes over time in patients' chronic angina.

Prevalence of nonfatal coronary heart disease among American adults

BACKGROUND

Few national estimates of the prevalence of coronary heart disease in the United States are available.

METHODS

By using data from the Third National Health and Nutrition Examination Survey (1988 to 1994), we estimated prevalence of angina pectoris by questionnaire, self-reported myocardial infarction, and electrocardiographically (ECG)-defined myocardial infarction.

RESULTS

Among participants aged >/=40 years who attended the medical examination, the age-adjusted prevalence of angina pectoris, self-reported myocardial infarction, and ECG-defined myocardial infarction were 5.8% of 9255, 6.7% of 9250, and 3.0% of 8206 participants, respectively. Among participants aged >/=65 years compared with those aged 40 to 64 years, the prevalence of a self-reported myocardial infarction was more than 3 times higher and that of ECG-defined myocardial infarction more than 4 times higher. The prevalences of self-reported myocardial infarction and ECG-defined myocardial infarction, but not angina pectoris, were higher among men than women. Among women, prevalence of angina pectoris and self-reported myocardial infarction were highest among blacks; among men, these coronary heart diseases were somewhat higher among whites. Prevalence of ECG-defined myocardial infarction were similar for all 3 race or ethnicity groups in either sex. The age-adjusted prevalence of coronary heart disease defined by the presence of any of these conditions was 13.9% among men and 10.1% among women.

CONCLUSIONS

Although the management of coronary heart disease has improved during the past 2 decades, it remains an important prevalent disease burden among adults.

Serum vitamins, carotenoids, and angina pectoris: findings from the National Health and Nutrition Examination Survey III

PURPOSE

Whether various vitamins and carotenoids can protect against ischemic heart disease remains an unsettled question.

METHODS

We performed a cross-sectional analysis of data from National Health and Nutrition Examination Survey III (1988-1994) and examined the associations between serum vitamins A, C, E, and B12, serum folate, red blood cell folate, serum carotenoids, and angina pectoris in a representative population-based sample of 11,327 men and women aged 35->90 years.

RESULTS

After adjusting for age, sex, race or ethnicity, education, smoking status, systolic blood pressure, serum cholesterol, high-density lipoprotein cholesterol, history of diabetes mellitus, body mass index, and physical activity with multiple logistic regression analysis, no significant associations were present for any of the serum vitamin concentrations and angina pectoris. Significant linear trends were observed for serum concentrations of alpha-carotene (p < 0.001), beta-carotene (p = 0.026), and beta-cryptoxanthin (p = 0.003). Compared with participants with carotenoid concentrations in the lowest quartile, participants with concentrations in the highest quartile had odds ratios for angina pectoris of 0.45 (95% confidence interval (CI) 0.31-0.65), 0.57 (95% CI 0.38-0.86), and 0.57 (95% CI 0.38-0.84) for alpha-carotene, beta-carotene, and beta-cryptoxanthin, respectively.

CONCLUSIONS

These results provide little support for a cross-sectional association between angina pectoris and serum and red blood cell folate concentrations or concentrations of vitamins A, C, E, and B12. Several serum carotenoid concentrations were associated with a reduced risk for angina pectoris, however.

Declining prevalence of angina pectoris in middle-aged men and women. A population-based study within the Northern Sweden MONICA Project. Multinational Monitoring of Trends and Cardiovascular Disease

OBJECTIVES

To describe trends in the prevalence of angina pectoris in northern Sweden, between 1986 and 1994.

DESIGN

Cross-sectional population studies.

SETTING

Northern Sweden MONICA Project in Norrbotten and Västerbotten counties, Sweden.

SUBJECTS

Randomly selected men and women in the age group 35-64 years, total of 2459 men and women.

MAIN OUTCOME MEASURES

Comparison of the prevalence of angina pectoris in 1986 and 1994 as measured by the Rose questionnaire.

RESULTS

The proportion with a history of myocardial infarction decreased amongst the participants from 4.6% to 2.0% (P < 0.001) between 1986 and 1994. The prevalence of angina pectoris in men was essentially unchanged (3.4% in 1986 to 3.1% in 1994 (chi2 = 0.02; P = 0.87), whereas it declined significantly in women from 5. 9% to 2.8% (chi2 = 6.32; P = 0.01). In both men and women, the highest prevalence of Rose-positive persons was found in the oldest age group. In 1986 the Rose-positive subgroup had a significantly higher proportion with high cholesterol (>/=6.5 mmol L-1) as compared with the Rose-negative subgroup, 64% vs. 48% (chi2 = 5.04; P = 0.02). In both surveys high blood pressure was more common in the Rose-positive group (1986: chi2 = 13.2; P < 0.001 and 1994: chi2 = 9.8; P = 0.002).

CONCLUSIONS

In women, but not in men, the prevalence of angina pectoris decreased significantly between 1986 and 1994. During the same time period the proportion of people with high cholesterol decreased in northern Sweden. In both surveys, individuals with angina pectoris had more frequent hypertension.

Prevalence of angina pectoris in Spain. PANES Study group

The frequency of coronary heart disease in a community is usually measured by myocardial infarction incidence and mortality rates. The measurement of the prevalence of angina pectoris may, however, become a convenient way of assessing coronary heart disease morbidity in the future. The aim of this study was to determine the prevalence of angina and validity of the Rose questionnaire in the Spanish population aged from 45 to 74 years. A cross-sectional study was conducted in 10,248 subjects (45-74 years), representative of the Spanish population. The WHO Rose questionnaire was used and a construct validation against regional mortality rates and cardiovascular risk factor prevalence was devised. The overall angina prevalence increased with age both in men and women, but was higher in the latter (7.3% and 7.7%, respectively). Angina prevalence also increased with the number of cardiovascular risk factors present and correlated with regional CHD mortality rates (r = 0.66). Sensitivity and specificity results of the Rose questionnaire were low when tested against exercise test (52.9% and 52.1%, respectively). As conclusions, Rose questionnaire is a reliable tool for assessing angina prevalence in the Spanish population which is similar to that of other industrialized countries with higher myocardial infarction morbidity and mortality.

Rose questionnaire angina in younger men and women: gender differences in the relationship to cardiovascular risk factors and other reported symptoms

Cross-sectional data from the Whitehall II study baseline were used to identify factors that may lead to the high levels of Rose angina reporting in women. 134 (4.0%) of 3350 women and 164 (2.4%) of 6830 men reported angina (P<0.001). Women with Rose angina had a poorer cardiovascular risk profile (degree of obesity, serum cholesterol and apolipoprotein B, blood pressure) and more electrocardiogram abnormalities (ST and T changes) than women without angina, but the associations were generally weaker than in men. Women who reported many other physical symptoms had a high prevalence of Rose angina (9.7%). Adjustment for symptom reporting reduced the age-adjusted gender difference to odds ratio (OR) = 0.93 (95% confidence interval [CI]: 0.56-1.56) for subjects with no symptoms, and to OR = 1.42 (95% CI = 1.05-1.90) for subjects at the upper quartile of symptom score. Among women a high level of general symptom reporting was associated with General Health Questionnaire (GHQ) minor psychiatric morbidity (51.9% prevalence), but GHQ caseness does not appear to be a predictor of Rose angina (OR 1.22 [0.67-2.21]) in this group. Coronary artery disease risk is raised in women with Rose angina, and this remains true in groups with high levels of general symptom reporting.

Prevalence and determinants of coronary heart disease in a rural population of India

BACKGROUND

The prevalence and determinants of coronary heart disease (CHD) have been inadequately studied in rural areas of developing countries.

METHODS

Entire communities were surveyed in randomly selected villages in Rajasthan, India. A physician-administered questionnaire, physical examination, and electrocardiogram (ECG) were performed on 3148 adults > or = 20 years of age (1982 males, 1166 females). Fasting blood samples for determination of lipids were obtained from 202 males and 98 females. Prevalence of coronary risk factors--smoking, hypertension, sedentary life-style, obesity, and hypercholesterolemia--was determined. CHD was diagnosed on basis of past documentation, response to WHO-Rose questionnaire, or changes in ECG. Three methods were used: (a) documentation, history, and ECG criteria, (b) ECG-Q, ST, or T changes, and (c) presence of Q waves.

RESULTS

Coronary risk factors: smoking was present in 51% males and 5% females, hypertension (> or = 140/90 mmHg) in 24% males and 17% females, hypercholesterolemia (> 200 mg/dl) in 22%, diabetes history in 0.2%, and irregular physical activity or sedentary habits in 85%. Other risk factors were lack of formal education in 44%, obesity (body-mass index > or = 27 kg/m2) in 6% and truncal obesity (waist-hip ratio > or = 0.95) in 5%. The prevalence of CHD (clinical + ECG criteria) was 3.4% in males and 3.7% in females. According to ECG criteria only, it was 2.8% in males and 3.3% in females and according to Q-waves only, it was 1.6% in males and 0.9% in females. Multivariate logistic regression analysis showed that age and smoking in males and age and systolic blood pressure in females were associated with higher prevalence of Q-wave CHD. In males, higher educational level and prayer habit were associated with lower prevalence.

CONCLUSIONS

Prevalence of CHD in this rural community is higher than in previously reported Indian studies. Smoking, hypertension, and sedentary lifestyle have high prevalence. Significant determinants of CHD are increasing age and smoking while education and prayer-habit are protective.

Repeatability and validity of the Rose questionnaire for angina pectoris in the Atherosclerosis Risk in Communities Study

Angina pectoris (AP) as determined by the Rose questionnaire was assessed in nearly 16,000 black and white men and women participating in the Atherosclerosis Risk in communities Study, a population study of cardiovascular disease in four communities. The questionnaire was administered at yearly intervals and estimates of repeatability were made. Validity was assessed indirectly by comparing Rose AP to risk factors, prevalent heart disease, medication use, and thickness of carotid artery walls as measured by B-mode ultrasound. Using kappa statistics for agreement of positive Rose AP determinations taken 1 year apart, white men show a higher level of agreement than white women (average kappa 0.36 for white men, 0.30 for white women), and whites show a higher level of agreement than blacks (average kappa 0.23 and 0.22 for black men and women, respectively). Rose AP that persists for more than one determination is associated with thicker carotid artery walls, greater amounts of cigarette smoking, greater prevalence of reported heart attack, and greater use of chest pain medications. A single determination of severe Rose AP is also associated with thicker carotid artery walls. These data suggest that multiple reports and the more severe grading of Rose AP (pain reported while walking on the level) are likely to indicate more severe disease; however, a single report using the Rose questionnaire appears valid, i.e., moderately associated with disease and risk factors, and appropriate for use in epidemiological studies.

Somatic awareness and coronary artery disease in women with chest pain

OBJECTIVE

To determine if there was a relationship between level of somatic awareness and coronary artery disease (CAD) in women with chest pain.

DESIGN

Descriptive, correlational study.

SETTING

Urban, university-affiliated, tertiary care hospital.

SAMPLE

Fifty-five women without a previous history of heart disease admitted to the hospital for evaluation of chest pain.

MEASURES

Modified Somatic Perception Questionnaire (MSPQ); Patterson and Horowitz clinical criteria for classification of chest pain; Supplemented Rose Questionnaire for angina; age; and CAD risk factors.

RESULTS

A small but significant inverse correlation was found between level of somatic awareness as measured by MSPQ scores and degree of CAD (r = 0.2932, p < 0.05). MSPQ scores significantly differed between women with CAD (lower scores) and women without CAD (higher scores) (p < 0.05). MSPQ score was the most important factor in a logistic regression model that modestly but significantly predicted presence or absence of CAD.

CONCLUSIONS

Somatic awareness may be an important factor to consider in evaluating the awareness and response of women to symptoms of myocardial ischemia and to chest pain of both cardiac and noncardiac etiologies.

Prodromal chest pains: clues to the pathogenesis of non-Q wave acute myocardial infarction?

Prodromal chest pains were recorded from consecutive admissions to a single coronary care unit and the symptoms of those with Q wave and non-Q wave acute myocardial infarction were compared. Of 809 admissions there were 201 with Q wave ad 88 with non-Q wave infarction. The non-Q wave infarction group was older, included more women and a greater proportion had suffered a previous myocardial infarct. Effort angina was equally common in both groups, but in the Q wave infarction group, angina was more often of recent onset, within the previous 4 weeks. Symptoms to indicate worsening angina, more prolonged, intense or frequent pain, were equally common in both groups. These findings suggest that although the extent of coronary artery disease may differ, Q wave and non-Q wave myocardial infarction share a common pathogenic mechanism.

Comparison of "Rose Questionnaire Angina" to exercise thallium scintigraphy: different findings in males and females

Validation of the London School of Hygiene (Rose) Questionnaire with objective measures of myocardial ischemia is incomplete. Therefore, we compared the Rose Questionnaire with exercise thallium-201 myocardial scintigraphy in 147 male and 97 female patients with chest pain referred for clinical exercise testing. Of those with "Rose Questionnaire angina", 26% of the females and 73% of the males had positive thallium-201 scans. Negative results on both the Rose Questionnaire and thallium-201 scintigraphy were observed in 71% of the females and 47% of the males. The sensitivity of the Rose Questionnaire was similar in females (41%) and males (44%). The specificity was 77% in males, while in females it was significantly lower at 56%. The specificity values reflect the higher (p less than 0.05) prevalence of "false positive" Rose Questionnaire results in females (75%) compared with males (27%). In addition, males had a greater (p less than 0.05) number of "false negative" results (53%) than females (29%). The accuracy of the Rose Questionnaire for myocardial ischemia was 0.19 in females, 0.48 in males, and 0.29 overall when including both males and females. Our results indicate a generally poor relationship between Rose Questionnaire angina and thallium-201 scintigraphy, an objective measure of myocardial ischemia in patients with chest pain referred to clinical exercise testing. Further, there are gender-specific differences in this relationship between the questionnaire and exercise thallium-201 imaging.