Typical angina during exercise stress testing improves the prediction of future acute coronary syndrome

Introduction: The prognostic value of angina during exercise stress testing is controversial, possibly due to previous studies not differentiating typical from non-typical angina. We aimed to assess the prognostic value of typical angina alone, or in combination with ST depression, during exercise stress testing for predicting cardiovascular events. Methods: We conducted a prospective observational cohort study including all patients who performed a clinical exercise stress test at the department of Clinical Physiology, Kalmar County Hospital between 2005 and 2012. The association between typical angina/ST depression and incident acute coronary syndrome (ACS) and cardiovascular mortality were analysed using Cox regression for long-term and 1-year follow-up. Results: Out of 11605 patients (median follow-up 6.7 years), 623 (5.4%) developed ACS and 319 (2.7%) died from cardiovascular causes. Compared to patients with no angina and no ST depression, typical angina and ST depression were associated with increased risk of future ACS; hazard ratio (HR) 3.5 ([95%CI] 2.6–4.7). This association was even stronger for ACS within one year (typical angina with and without concomitant ST depression; HR 20.8 (13.9–31.3) and 9.7 (6.1–15.4), respectively). Concordance statistics for ST depression in predicting ACS during long-term follow-up was 0.58 (0.56–0.60) and 0.69 (0.65–0.73) for ACS within one year, and 0.64 (0.62–0.66) and 0.77 (0.73–0.81), respectively, when typical angina was added to the model. Conclusions: Typical angina during exercise stress testing is predictive of future ACS, especially in combination with ST depression, and during the first year after the test