Predicting death from coronary heart disease using a questionnaire

Prevalence and factors associated with undiagnosed and uncontrolled heart disease: A study based on self-reported chronic heart disease and symptom-based angina pectoris among middle-aged and older Indian adults

BACKGROUND

This study aimed to examine the prevalence of heart diseases and angina pectoris and associated factors among middle-aged and older Indian adults. Additionally, the study examined the prevalence and associated factors of undiagnosed and uncontrolled heart disease among middle-aged and older adults based on self-reported chronic heart disease (CHD) and symptom-based angina pectoris (AP).

METHODS

We used cross-sectional data from the first wave of the Longitudinal Ageing Study of India, 2017-18. The sample consists of 59,854 individuals (27, 769 males and 32,085 females) aged 45 years and above. Maximum likelihood binary logistic regression models were employed to examine the associations between morbidities, other covariates (demographic factors, socio-economic factors and behavioral factors) and heart disease and angina.

RESULTS

A proportion of 4.16% older males and 3.55% older females reported the diagnosis of heart diseases. A proportion of 4.69% older males and 7.02% older females had symptom-based angina. The odds of having heart disease were higher among those who were hypertensive and who had family history of heart disease, and it was higher among those whose cholesterol levels were higher. Individuals with hypertension, diabetes, high cholesterol and family history of heart disease were more likely to have angina than their healthy counterparts. The odds of undiagnosed heart disease were lower but the odds of uncontrolled heart disease were higher among those who were hypertensive than non-hypertensive individuals. Those having diabetes were less likely to have undiagnosed heart disease while among the diabetic people the odds of uncontrolled heart disease were higher. Similarly, higher odds were observed among people with high cholesterol, having stroke and also among those who had a history of heart disease than their counterparts.

CONCLUSIONS

The present study provided a comparative prevalence of heart disease and agina and their associations with chronic diseases among middle-aged and older adults in India. The higher prevalence of undiagnosed and uncontrolled heart disease and their risk factors among middle-aged and older Indians manisfest alarming public health concerns and future health demand.

Are Russian Men with Intermittent Claudication and/or Angina Pectoris Have the Same Cardiovascular and All-Cause Mortality Risks? The Data of the Prospective Population-Based Study

Aim. To investigate the distribution of the intermittent claudication(IC) and/or angina pectoris (AP) and to evaluate the risk of cardiovascular and allcause mortality in Russian male population with pain syndrome of varying severity during more than 30-year observation period.

Material and methods. The data were obtained from representative samples observed in Moscow and Saint-Petersburg (former Leningrad) from 1975 to 1986 with 75% response. Men (n=10953) aged 35-71 years (mean age 48.8±6.6 years) were examined by the same protocol which includes standard questionnaire, blood biochemistry, blood pressure (BP) and heart rate measurements, anthropometry and electrocardiography (ECG) in 12 leads. The original Rose questionnaire to determine the IC and AP was used. There were defined five risk groups with different pain features. The first group – no pain; the second group – mixed pain in legs and/or in chest including the pain connected with the effort, but without typical IC and AP features; the third group – only IC without AP; the fourth group – only AP without IC; finally, the fifth group – both IC and AP. The median follow-up period was 21.9 years with interquartile range of 13.4-33.5 years. During the follow-up 7893 all-cause deaths including 4220 cardiovascular deaths were found. The Kaplan-Meier method was applied to find out the associations between risk groups and survival. Mortality risk, including cardiovascular mortality, was evaluated by the Cox proportional hazard model.

Results. There were 38.7% men with any pain. The prevalence of IC without AP was 0.7% and the prevalence of AP without IC was 5.8%. Only 0.3% of the population had both IC and AP. The prevalence of both parameters increased with age. As expected, men with no pain live longer than others. Median of the survival time in this group, which means the point when half of the population dies, was 24.9 years. Only in this group the value when 75% of population dies was not reached. Compared to no pain group, loss of the life expectancy of only IC group was 10.9 years, only AP group – 9.2 years, IC and AP group – 17.9 years. Both IC and AP had statistically significant contribution to mortality adjusted for high blood pressure, smoking, presence of ECG disturbances, history of myocardial infarction. Survival curves of isolated IC and AP groups did not have statistically significant difference which means that both diseases have the same contribution to mortality. Similar results were obtained for cardiovascular mortality.

Conclusion. The prevalence of IC without AP was 0.7% and the prevalence of AP without IC was 5.8%. IC and AP are independent factors of all-cause and cardiovascular mortality among the Russian male population aged 35-71 years. However, no statistically significant difference was found between groups only with IC and only with AP for cardiovascular and all-cause deaths. The presence of both conditions in combination reduces the median survival time by 17.9 years compared to the group with no pain.

Determinants of premature mortality in a city population: an eight-year observational study concerning subjects aged 18-64

BACKGROUND

Premature deaths constitute 31.1% of all deaths in Łódź. Analysis of the causes of premature deaths may be helpful in the evaluation of health risk factors. Moreover, findings of this study may enhance prophylactic measures.

MATERIAL AND METHODS

In 2001, 1857 randomly selected citizens, aged 18-64, were included in the Countrywide Integrated Noncommunicable Diseases Intervention (CINDI) Programme. In 2009, a follow-up study was conducted and information on the subjects of the study was collected concerning their health status and if they continued to live in Łódź. The Cox proportional hazards model was used for evaluation of hazard coefficients. We adjusted our calculations for age and sex. The analysis revealed statistically significant associations between the number of premature deaths of the citizens of Łódź and the following variables: a negative self-evaluation of health - HR = 3.096 (95% CI: 1.729-5.543), poor financial situation - HR = 2.811 (95% CI: 1.183-6.672), occurring in the year preceding the study: coronary pain - HR = 2.754 (95% CI: 1.167-6.494), depression - HR = 2.001 (95% CI: 1.222-3.277) and insomnia - HR = 1.660 (95% CI: 1.029-2.678). Our research study also found a negative influence of smoking on the health status - HR = 2.782 (95% CI: 1.581-4.891). Moreover, we conducted survival analyses according to sex and age with Kaplan-Meier curves.

CONCLUSIONS

The risk factors leading to premature deaths were found to be highly significant but possible to reduce by modifying lifestyle-related health behaviours. The confirmed determinants of premature mortality indicate a need to spread and intensify prophylactic activities in Poland, which is a post-communist country, in particular, in the field of cardiovascular diseases.

The relationship between depression, anxiety and cardiovascular disease: findings from the Hertfordshire Cohort Study

BACKGROUND

Previous studies suggest a link between depression, anxiety and cardiovascular disease (CVD). The aim of the study was to determine the relationship between depressive and anxiety symptoms and CVD in a population based cohort.

METHODS

In total 1578 men and 1,417 women from the Hertfordshire Cohort Study were assessed for CVD at baseline and after 5.9 ± 1.4 years. Depressive and anxiety symptoms were measured using the HADS scale.

RESULTS

Baseline HAD-D score, but not HAD-A, was significantly associated with baseline plasma triglycerides, glucose and insulin resistance (men only) and HDL cholesterol (women only). After adjustment for CVD risk factors, higher baseline HAD-D scores were associated with increased odds ratios for CVD (men: 1.162 [95% CI 1.096-1.231]; women: 1.107 [1.038-1.181]). Higher HAD-A scores associated with increased CVD in men only. High HAD-D scores predicted incident CVD (adjusted OR 1.130 [1.034-1.235]), all-cause mortality (adjusted HR 1.081, [1.012-1.154]) and cardiovascular mortality (adjusted HR 1.109 [1.002-1.229]) in men but not in women.

LIMITATIONS

The use of a self-report measure of depressive and anxiety symptoms, 'healthy' responder bias and the low number of cardiovascular events are all limitations.

CONCLUSIONS

Depressive and anxiety symptoms are commoner in people with CVD. These symptoms are independent predictors of CVD in men. Although HAD-D score was significantly associated with several cardiovascular risk factors, this did not fully explain the association between HAD-D and CVD.

Gene polymorphisms and low dietary intake of micronutrients in coronary artery disease

BACKGROUND/AIMS

Coronary artery disease (CAD) is a complex disorder involving genetic and non-genetic factors. Food is an important component of the latter. We examined if DNA polymorphisms in genes encoding enzymes of one-carbon metabolism coupled with low consumption of micronutrients such as folate, vitamins B(6) and B(12) might increase the risk of CAD.

METHODS

A case-control study consisting of 252 CAD patients and 252 controls were included. Three single nucleotide polymorphisms (SNP), 2 insertion/deletion and 1 repeat polymorphism were typed. The micronutrient intake was estimated from a standard 24-hour dietary recall coupled to a food frequency questionnaire.

RESULTS

The results suggest an association of 'early-onset CAD' with betaine homocysteine S-methyl transferase (BHMT) 742G→A SNP (odds ratio = 1.52; 95% confidence interval, 0.96-2.41; p = 0.04). No association was observed for all age of onset, but more patients than controls whose micronutrient intake was in the lowest quintile also carried the minor allele (50% patients vs. 37% controls; p = 0.042). Furthermore, dietary intake of folate micronutrients below the recommended daily allowance was observed in a larger percent of patients than controls with the minor BHMT allele (51% patients vs. 44% controls; p = 0.021).

CONCLUSIONS

In the presence of the minor BHMT allele, a decreased consumption of folate micronutrients might increase the risk of CAD.

Nicotine dependence and urge to smoke predict negative health symptoms in smokers

OBJECTIVE

To assess the predictive value of nicotine dependence or urge to smoke for negative health symptoms one year later.

METHODS

Subjects were smokers (N=1519) from the US, Canada, UK, France and Spain participating in the internet based ATTEMPT study between 2004 and 2006, a multi-national prospective cohort study. Nicotine dependence was assessed by the Fagerström Test for Nicotine Dependence (FTND) and urge to smoke by the 10-item version of the Questionnaire of Smoking Urges (QSU-10). Specific questions were used to assess presence of chest pain specified as angina pectoris, shortness of breath, depressive mood, feeling of anxiety and visit at a primary care physician, an index of global health and health care, one year after assessment of FTND and QSU-10.

RESULTS

Smokers who reported angina pectoris, shortness of breath, low mood, anxiety or visit at a primary care physician 9 to 12 months after assessment have significantly higher FTND and QSU-10 scores than those who did not report these negative health symptoms or who did not visit a primary care physician.

CONCLUSION

Smokers with high level of nicotine dependence or urge to smoke are at higher risk of negative health symptoms than those who have low levels of nicotine dependence or urge to smoke.

Angina pectoris is a stronger indicator of diffuse vascular atherosclerosis than intermittent claudication: Framingham study

OBJECTIVE

To compare implications of Angina Pectoris (AP) and Intermittent Claudication (IC) as indicators of clinical atherosclerosis in other vascular territories.

STUDY DESIGN AND SETTING

Prospective cohort study of cardiovascular disease (CVD) in 5,209 men and women of Framingham, MA, aged 28-62 years at enrollment in 1948-1951, who received biennial examinations during the first 36 years of follow-up. Comparative 10-year incidence of subsequent atherosclerotic CVD in participants with IC and AP relative to a reference sample free of CVD was determined.

RESULTS

On follow-up, 95 CVD events occurred in 186 participants with IC and 206 of 413 with AP. After age, sex, and risk-factor adjustment, the proportion acquiring other CVD was 34.0% for IC and 43.4% for AP. Relative to the reference sample, those with IC had a 2.73-fold higher age and sex-adjusted 10-year hazard of CVD (95% CI 2.21, 3.38) and for AP was 3.17 (95% CI 2.73, 3.69). CVD hazard ratios remained more elevated for AP and statistically significant after standard risk factor adjustment. Risk factors accounted for more of the excess CVD risk associated with IC (34.8%) than AP (9.5%).

CONCLUSION

AP is as useful as IC as a hallmark of diffuse atherosclerotic CVD and an indication for comprehensive preventive measures.

Associations between working conditions and angina pectoris symptoms among employed women

OBJECTIVE

This study aimed to examine whether psychosocial working conditions are associated with angina pectoris (AP) symptoms in women.

METHODS

Data were derived from postal questionnaires filled in by 40- to 60-year-old women employed by the City of Helsinki, Finland, in 2000 to 2002 (n = 7093, response rate 67%). AP symptoms were measured by the Rose Questionnaire. Logistic regression analyses were carried out to examine AP symptoms as outcome. Independent variables consisted of Karasek's job demands and job control, work fatigue, working overtime, work-related mental and physical strain, the work-home interface, and social support, adjusted for age. Confounding effects of socioeconomic status, health behaviors (smoking, binge drinking, body mass index), and menopause were also examined. Pregnant women were excluded.

RESULTS

AP symptoms were reported by 6% of participants. Work fatigue was strongly associated with AP. In addition, working overtime, low job control, and high physical strain at work were associated with AP. The associations between psychosocial working conditions and AP symptoms were unaffected by health behaviors, socioeconomic status, or menopause.

CONCLUSIONS

Working conditions were associated with the AP symptoms identified by the Rose Questionnaire. Longitudinal studies are needed to disentangle the causal relationships, i.e., whether psychosocial stress is a true risk factor/cause of angina symptoms and cardiovascular disease among women.

A simple score for predicting coronary artery disease in patients with chest pain

BACKGROUND

We have previously derived a chest pain score by comparing those with and without coronary artery disease on angiography, which was subsequently validated in patients attending coronary angiography.

AIM

To test the predictive validity of the score prospectively in a more varied out-patient population, and to determine whether it had predictive validity in addition to exercise testing.

DESIGN

Prospective clinical study.

METHODS

The score was applied to 405 out-patients with chest pain who subsequently underwent coronary angiography. Framingham risk analysis and exercise testing were performed in 155.

RESULTS

The score had a sensitivity of 91.4% and specificity of 28% for coronary artery disease, which was found in 31.8%, 51%, 63%, and 82% of those with scores of 0, 1, 2, and 3, respectively. Gender (p < 0.001), age (p < 0.001), and chest pain score (p = 0.009) independently predicted coronary artery disease on multivariate Poisson regression analysis. The chest pain score had additive predictive value with Framingham risk analysis and Duke's score.

DISCUSSION

This simple chest pain score can predict coronary anatomy with similar sensitivity to exercise testing, and can be used in conjunction with exercise testing and other measures. Further validation of the chest pain score in the primary care setting will be useful.

Variations in high-density lipoprotein cholesterol in relation to physical activity and Taq 1B polymorphism of the cholesteryl ester transfer protein gene

The aim of the study was to determine any association of physical activity and Taq 1B polymorphism in the cholesteryl ester transfer protein gene on high-density lipoprotein (HDL) cholesterol. Five hundred and four subjects, 390 males and 114 females consisting of an equal number of age- and sex-matched healthy controls and patients with coronary artery disease, were included. The mean age (+/-SD) of the patients and controls were 57.5 +/- 10.6 years and 56.8 +/- 11.0 years, respectively. All the patients underwent coronary angiography; 33, 58, 63, and 98 patients had normal coronaries, single-, two-, or triple-vessel disease, respectively. A third of the patients had suffered from a myocardial infarction. The genotype distribution conforming to Hardy-Weinberg equilibrium was similar for cases and controls. The mean HDL cholesterol increased from B1B1 through B2B2 genotype in controls and sedentary male patients. Self-reported leisure time physical activity, consisting mostly of an hour of morning walk daily, was associated with a rise in mean HDL cholesterol in male controls (33.6 +/- 7.9 mg/dl to 36.2 +/- 8.9 mg/dl, p = 0.037) and patients (32.4 +/- 7.9 mg/dl to 35.7 +/- 11.0 mg/dl; p = 0.018). The exercise-associated rise in HDL cholesterol was most pronounced in controls (32.1 +/- 9.1 mg/dl to 36.8 +/- 9.3 mg/dl, p = 0.05) and male patients (30.5 +/- 7.4 mg/dl to 37.2 +/- 9.7 mg/dl, p = 0.007) with B1B1 rather than B1B2 or B2B2 genotype. The results suggest a possible gene-environment interaction in the regulation of HDL cholesterol that needs to be confirmed in other populations and larger samples to rule out a chance occurrence.

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.

Prevalence of dementia in three ethnic groups: the South Florida program on aging and health

To determine the prevalence of cognitive impairment and dementia in a multi-ethnic community, we examined a population sample of 2,759 elderly (65 years of age and older) African American, Hispanic-Cuban and white non-Hispanic men and women of Dade County, Florida. The Short Portable Mental Status Questionnaire (SPMSQ) was used as a screening test. The prevalence of cognitive impairment for African American men was 17.0% and women 16.7%; Cuban men 9.4% and women 11.4%; and white non-Hispanic men 9.0% and women 8.5%. Participants with cognitive impairment were referred to two Memory Disorder Clinics for diagnosis of dementia/Alzheimer's disease (AD). SPMSQ cutpoints took account of race and education. The prevalence of dementia/AD was adjusted for sensitivity and specificity of the SPMSQ in each sex/ethnic group. The prevalence of dementia among African American men (20.9%) was twice that among white non-Hispanic men (11.6%). White non-Hispanic and Cuban women had a similar prevalence of dementia (12.1% vs. 12.9%). Low SPMSQ specificity for Cuban men and African American women gave unstable dementia prevalence estimates. More than two thirds of all dementia cases had AD, and among white non-Hispanics, women had double the prevalence of AD among men (10.9% vs. 5.4%). The prevalence of AD among African American men was more than two and a half times greater than the prevalence among white non-Hispanic men (14.4% vs. 5.4%). Age (p = 0.001), family history of AD (p = 0.02) and African American (p = 0.0001) or Cuban (p = 0.006) ethnic group were directly and independently associated with the prevalence of AD.

The MRC trial of assessment and management of older people in the community: objectives, design and interventions [ISRCTN23494848]

BACKGROUND

The benefit of regular multidimensional assessment of older people remains controversial. The majority of trials have been too small to produce adequate evidence to inform policy. Despite the lack of a firm evidence base, UK primary care practitioners (general practitioners) are required to offer an annual health check to patients aged 75 years and over.

DESIGN

Cluster-randomised factorial trial in primary care comparing a package of assessments (i) universal versus targeted assessment and (ii) management by the primary care team (PC) or a multidisciplinary geriatric assessment team (GM). The unit of randomization is the general practice.

METHODS

Older people aged 75 and over eligible for the over 75s health check and excluding those in nursing homes or terminally ill were invited to participate. All participants receive a brief assessment covering all areas of the over 75s check. In the universal arm all participants also receive a detailed health and social assessment by a study nurse while in the targeted arm only participants with a pre-determined number and range of problems at the brief assessment go on to have the detailed assessment. The study nurse follows a standard protocol based on results and responses in the detailed assessment to make referrals to (i) the randomised management team (PC or GM) (ii) other medical services, health care workers or agencies (iii) emergency referrals to the GP. The main outcomes are mortality, hospital and institutional admissions and quality of life. 106 practices and 33,000 older people have been recruited to the trial.

A low prevalence of the C677T mutation in the methylenetetrahydrofolate reductase gene in Asian Indians

The prevalence of the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene in Asian Indians from India was determined and the association of the mutant allele with coronary artery disease (CAD) was evaluated in a case-control study. The case group consisted of 251 patients with CAD; 195 male and 56 female aged from 29 to 82 years (mean age +/- SD, 57.5 +/- 10.6 years). The control group consisted of 216 apparently healthy individuals without evidence of CAD; 161 male and 55 female aged from 30 to 83 years (mean age +/- SD, 54.9 +/- 10.4 years). All the patients were assessed by coronary angiography. While 33 patients had normal coronaries, 23, 25 and 39 patients had single-vessel, two-vessel and triple-vessel disease, respectively. Eighty-three patients (33%) had suffered myocardial infarction less than a year to five years earlier. The C677T polymorphism in the MTHFR gene was assessed. While 31% of the controls and 38% of the patients had the heterozygous genotype, 2% of the control group and none of the patients had the mutant homozygous genotype. The overall 'T' allelic frequencies were comparable in control and patient groups (0.18 and 0.19, respectively), but the association of the sum of heterozygous and homozygous genotypes with CAD (1, 2 or 3-vessel disease) was statistically significant for females only [Odds ratio (95% confidence intervals), 2.8 (1.1-6.9), p = 0.023]. No association was found between genotype distribution and previous myocardial infarction or severity of atherosclerosis.

Do socioeconomic disadvantages persist into old age? Self-reported morbidity in a 29-year follow-up of the Whitehall Study

OBJECTIVES

This study examined (1) the relation of employment grade in middle age to self-reported poor health and functional limitations in old age and (2) whether socioeconomic status at approximately the time of retirement modifies health differentials in old age.

METHODS

Survivors of the Whitehall Study cohort of men were resurveyed. Respondents were aged 40 to 69 years when they were originally screened in 1967 to 1970.

RESULTS

Compared with senior administrators, men in clerical or manual (low-grade) jobs in middle age had quadruple the odds of poor physical performance in old age, triple the odds of poor general health, and double the odds of poor mental health and disability. At most, 20% of these differences were explained by baseline health or risk factors. Men who moved from low to middle grades before retirement were less likely than those who remained in low grades to have poor mental health.

CONCLUSIONS

Socioeconomic status in middle age and at approximately retirement age is associated with morbidity in old age.

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.

Knowledge and beliefs about transmission, prevention and control of lymphatic filariasis in rural areas of south India

To identify the gaps in people's knowledge of lymphatic filariasis, we collected descriptive and quantitative information in rural areas of Tamil Nadu, South India. People are well aware of filariasis in their communities and recognize its different clinical manifestations. Only 9% of those with and 20% of those without the disease knew that filariasis is caused through mosquito bites; the rest attributed it to many other causes. People's knowledge about transmission and prevention of filariasis is also very poor. The study identifies the rationale for people's misconceptions about the disease. Misconceptions and ignorance could adversely affect personal protection measures against mosquito bites and the use of appropriate treatment. Health education campaigns aimed at highlighting the role of mosquitoes in transmission and the importance of early diagnosis should help people in taking personal protection measures and seeking appropriate treatment.

Incidence, clinical characteristics, and short-term prognosis of angina pectoris

OBJECTIVES

To estimate the clinical incidence and short-term prognosis of patients presenting with typical angina pectoris in the general population.

DESIGN

Prospective survey of all patients referred by 117 general practitioners from a random sample of 17 general practices serving a population of 191,677 with a median follow up of 16 months.

SETTING

A special open access chest pain clinic, based in the non-invasive cardiology department of a teaching hospital, set up for this study.

PATIENTS

110 consecutive patients < or = 70 years age with no history of coronary heart disease presenting for the first time with typical angina.

MAIN OUTCOME MEASURES

Age and sex specific incidences, persistence of chest pain, revascularisation procedures, myocardial infarction, and death.

RESULTS

The crude annual incidence of angina pectoris (95% confidence interval) was 0.83 (0.66 to 1.0) per thousand population aged 31-70 years; the rates were 1.13 (0.85 to 1.40) for men and 0.53 (0.33 to 0.72) for women. On resting electrocardiography 5% of patients had > or = 1 mm horizontal or downsloping ST depression, 5% had Q/QS patterns, and in one (1%) there was complete left bundle branch block. Among the 103 patients who underwent a Bruce protocol exercise test, 29% had > or = 3 mm ST segment depression induced at a low workload. Of 107 patients at a median (range) follow up of 15.8 (7-30) months, angina remitted spontaneously in 12 patients (11%), 20 (19%) underwent revascularisation, eight (7%) sustained a non-fatal myocardial infarction, and four (4%) died.

CONCLUSION

Incidence of new cases of angina pectoris in the United Kingdom is conservatively estimated from this study to be 22,600 patients per annum. Almost one third of these patients will have positive exercise tests at low workload, so the potential for coronary angiography and revascularisation is considerable. With one in 10 patients experiencing a non-fatal myocardial infarction or coronary death within a year of presentation the prognosis of angina is not benign. Further research is required to identify those patients in the general population who would benefit most from coronary revascularisation.