Chest pain on questionnaire and coronary heart disease in British men

Angina is a common manifestation of coronary heart disease (CHD). It is usually managed in primary care, and possibly many cases are medically undetected. This thesis investigates the prevalence, prognosis, and diagnosis of angina from a population-based perspective, using data from repeated questionnaires and medical record reviews in the British Regional Heart Study, a study of 7735 middle-aged men followed from 1978 to 1997. Diagnosed angina and angina symptoms (effort-induced chest pain) were common. Angina was a very strong risk factor for major CHD and cardiovascular events, but prognosis was better than that for definite myocardial infarction. Excess risk diminished with increasing event-free survival, and classical risk factors (age, smoking, blood pressure, cholesterol) determined the level of risk. Although diagnosed angina conferred higher risk than symptoms only, effort-induced chest pain among men without diagnosed CHD was strongly predictive of major CHD events, and should be considered an indicator of unrecognised CHD. Effort-induced chest pain increased risk whether or not all the additional classical angina criteria were fulfilled, but CHD was more likely to be diagnosed if symptoms conformed to the classical definition. This suggests the need for re-appraisal of angina diagnostic criteria. The results did not suggest an important role of social class in the prognosis, diagnosis or investigation of angina. The strongest determinant of referral to secondary care was age (inverse association). Over the study period, the major CHD event rate fell among men with and without pre-existing CHD. The prevalence of angina symptoms also fell, but the prevalence of diagnosed CHD remained stable, emphasising the ongoing burden of CHD and need for treatment. This study provides insight into the burden and prognosis of diagnosed angina and angina-like chest pain, and has implications for diagnosis and management of angina in clinical practice and measurement of angina in epidemiological studies