Do patients with angina alone have a more benign prognosis than patients with a history of acute myocardial infarction, revascularisation or both? Findings from a community cohort study

B Buckley; A W Murphy

doi:10.1136/hrt.2008.146944

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Coronary artery disease

Do patients with angina alone have a more benign prognosis than patients with a history of acute myocardial infarction, revascularisation or both? Findings from a community cohort study

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How do you measure a clinical history?
M Justin S Zaman
Published on: 23 November 2015
Mechanisms of angina
MJ Quinn
Published on: 23 November 2015

Published on: 23 November 2015
How do you measure a clinical history?
- M Justin S Zaman, Academic Clinical Lecturer in Cardiology
Buckley and Murphy present a timely reminder of the need to study chronic symptomatic conditions,[1] as increasingly these conditions represent the bulk of where coronary disease presents,[2] shifting away from presenting acutely to secondary care. A better understanding of angina is thus vital.
The paper’s pragmatic definition of angina, and the accompanying editorial by Hemingway, [3] remind us all that angin...
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Buckley and Murphy present a timely reminder of the need to study chronic symptomatic conditions,[1] as increasingly these conditions represent the bulk of where coronary disease presents,[2] shifting away from presenting acutely to secondary care. A better understanding of angina is thus vital.
The paper’s pragmatic definition of angina, and the accompanying editorial by Hemingway, [3] remind us all that angina is initially diagnosed from a clinical constellation of symptoms from the patient history. Descriptions of symptoms, articulated by patients to their doctors, remain a cornerstone of diagnosis in clinical medicine. The clinical history is the first step in assessing chest pain or discomfort in order to ascertain whether or not it represents angina. The history also allows the doctor to identify patients in whom additional investigation is necessary and in whom it may be spared. While laboratories standardise assays for biomarkers in the measurement of a myocardial infarction, angina is a clinical constellation of symptom descriptors, rendering quantitative measurement difficult.
The difficulty in measuring angina as a phenotype was highlighted with the finding that the reliability of the Rose angina questionnaire was reported in a 2001 cross-sectional study to be inconsistent in South Asian populations when compared to self-reported doctor-diagnosed angina and independently coded electrocardiogram (ECG) abnormalities.[4] The Rose Angina Questionnaire has been used as a cardiovascular disease health indicator for decades and is still in widespread use in epidemiological studies. However, the Rose Angina Questionnaire was developed as a screening tool in Western countries when coronary heart disease incidence and mortality was far higher than today. Though studies consistently find a strong positive association of Rose angina with coronary mortality [5], it’s cross-sectional and prognostic validity, especially in developing countries who currently lie on the ascending limb of their predictable coronary disease epidemic curve, is far from certain. More discriminating measurement of angina symptoms, focusing more on the description of the chest pain, may complement existing angina assessment. Using a multi- centre chest pain clinic cohort, descriptors of chest pain using a simple symptom score were predictive of coronary events across sex and ethnicity.[6] However, significant numbers of patients with atypical histories remained at risk of future coronary events.
Appropriate identification and treatment at incident symptomatic presentations of coronary disease such as angina may prevent or at least delay progression to more serious later manifestations of coronary disease such as myocardial infarction and coronary death, improved prognostic measures of symptoms in primary care are of further importance. Rather than focusing on myocardial infarction, as much of developed world research has done over the last 30 years in cardiology, a paradigm shift to the study of ‘stage 1’ coronary disease – or incident angina – is merited in preparedness for the upcoming coronary tsumani heading for today’s developing countries.
1. B Buckley and A W Murphy. Do patients with angina alone have a more benign prognosis than patients with a history of acute myocardial infarction, revascularisation or both? Findings from a community cohort study. Heart 2009; 95: 461-467 2. Sekhri N, Feder GS, Junghans C, Hemingway H, Timmis AD. Rapid-access chest pain clinics and the traditional cardiology out-patient clinic. QJM 2006;99(March 1, 2006):135-141. 3. States, rates and traits: prognosis research and chronic stable angina. Harry Hemingway, H. Heart 2009 95: 439-440 4. Fischbacher CM, Bhopal R, Unwin N, White M, Alberti K. The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK. Int. J. Epidemiol. 2001;30(5):1009-1016. 5. Wilhelmsen L, Rosengren A, Hagman M, et al. "Nonspecific" chest pain associated with long-term mortality: results from the primary prevention study in Göteborg, Sweden. Clin Cardiol 1998: 21: 477–82 6. Zaman MJ, Junghans, C., Sekhri, N., Chen, R., Feder, G., Timmis, A., Hemingway, H. Presentation of stable angina pectoris among women and South Asian people. CMAJ. 2008 September 23;179(7):659-67.
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Conflict of Interest:
None declared.
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Published on: 23 November 2015
Mechanisms of angina
- MJ Quinn, Consultant in Gynaecology
Angina is traditionally thought to be “ischaemic” in origin with increasing demands for blood in the myocardium giving rise to visceral pain. Prolonged ischaemia leads to myocardial infarction. The prognosis for each condition may depend on their varying aetiologies (1). Recent studies demonstrate aberrant myocardial reinnervation in ventricular arrhythmias, cardiomyopathies and following myocardial infarction; in some...
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Angina is traditionally thought to be “ischaemic” in origin with increasing demands for blood in the myocardium giving rise to visceral pain. Prolonged ischaemia leads to myocardial infarction. The prognosis for each condition may depend on their varying aetiologies (1). Recent studies demonstrate aberrant myocardial reinnervation in ventricular arrhythmias, cardiomyopathies and following myocardial infarction; in some circumstances peri-arteriolar reinnervation takes place (2).
Concentric layers of periarteriolar nerves occur in uterine smooth muscle causing sustained, visceral pain in the week prior to menstruation (3). These lesions often accompany widespread aberrant reinnervation in specific areas of uterine muscle, specifically the uterine isthmus where primary neurovascular bundles enter the viscus. Sources of injury include persistent straining during defaecation and traumatic injuries sustained in childbirth (3, 4).
Few gynaecologists are familiar with the morphology of the inferior hypogastric and uterovaginal plexi (5). Widespread use of formalin to preserve cadavers for medical education in the post-war years, selectively destroys fine, autonomic nerves (5). However, both uterine and cardiac ganglia were familiar to nineteenth century anatomists dissecting fresh cadaveric material (6). Does periarteriolar reinnervation, or, aberrant myocardial reinnervation, account for some forms of angina or acute myocardial infarction, and their varying prognoses ?
MJ Quinn MD, LLM. Fulham, London, SW6.
(1) Buckley B, Murphy AW. Do patients with angina alone have a more benign prognosis than patients with a history of acute myocardial infarction, revascularisation or both? Findings from a community cohort study. Heart 2009;95:461-467.
(2) Cao JM, Fishbein MC, Han JB, Lai WW, Lai AC, Wu TJ, Czer L, Wolf PL, Denton, TA, Shintaku IP, Chen PS, Chen LS. Relationship between regional cardiac hyperinnervation and ventricular arrhythmia. Circulation 2000;101(16):1960-9.
(3) Quinn MJ. Perivascular nerve fibre proliferation: the consequence of chronic straining. J Obstet Gynaecol 2007; 27(2): 185-8.
(4) Tokushige N, Markham R, Russell P, Fraser IS. Different types of small nerve fibers in eutopic endometrium and myometrium in women with endometriosis. Fertil Steril. 2007; 88(4):795-803.
(5) Spackman R, Wrigley B, Roberts A, Quinn M. The inferior hypogastric plexus: a different view. J Obstet Gynaecol. 2007;27(2):130-3.
(6) Lee R. Engravings of the Ganglia and Nerves of the Uterus and Heart. London, 1858.
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Conflict of Interest:
None declared.
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