Breathlessness, angina pectoris and coronary artery disease

doi:10.1016/0002-9149(89)90140-9

The American Journal of Cardiology

Volume 63, Issue 13, 15 April 1989, Pages 921-924

https://doi.org/10.1016/0002-9149(89)90140-9 Get rights and content

Abstract

The relation of breathlessness to angina was examined in 7,735 middle-aged British men. Among men who did not report breathlessness, the age-standardized prevalence rate of angina was 4%. In men with mild, moderate or severe breathlessness, the prevalence rates of angina were 16, 29 and 41%, respectively. The association between breathlessness and angina was independent of age or cigarette smoking, with similar relations observed in men who had never smoked. The prevalence of electrocardiograms revealing ischemia increased with the severity of breathlessness, even in men without angina or other evidence of coronary artery disease (CAD) at screening. In men with a low forced expiratory volume in 1 second, the prevalence of angina was also increased, but the association was much weaker than that observed between angina and breathlessness. After a 5-year follow-up, 25% of men severely breathless at screening but without any initial evidence of CAD had developed angina, 5% had had a heart attack (half of these were fatal) and 7% were dead from causes other than CAD. The corresponding rates for men not breathless at screening and without evidence of CAD were: 4% angina, 2.5% heart attack and 2% dead from causes other than CAD. Breathlessness appears to be an early indicator of CAD in the absence of either angina or electrocardiographic evidence of ischemia.

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Cited by (34)

Stable angina pectoris
2017, Coronary Artery Disease: From Biology to Clinical Practice
Stable coronary artery disease (SCAD) is generally characterized by episodes of reversible myocardial demand/supply mismatch, related to ischemia or hypoxia, which are usually inducible by exercise, emotion, or other stress and reproducible but also may be occurring spontaneously. Such episodes of ischemia/hypoxia are commonly associated with transient chest discomfort (angina pectoris). SCAD also includes the stabilized, often asymptomatic, phases that follow an acute coronary syndrome. Within the population with stable coronary artery disease, an individual's prognosis can vary considerably, depending on baseline clinical, functional, and anatomical characteristics. Prognostic assessment is an important part of the management of patients with stable angina. On the one hand, it is important to reliably identify those patients with more severe forms of disease, who may have an improvement in outcome with more aggressive investigation and—potentially—intervention, including revascularization. On the other hand, it is also important to identify those patients with a less-severe form of disease and a good prognosis, thereby avoiding unnecessary invasive and noninvasive tests and revascularization procedures.
Prevalence of Cardiovascular Disease and Cardiac Symptoms: Left and Right Ventricular Function in Adults With Osteogenesis Imperfecta
2015, Canadian Journal of Cardiology
Citation Excerpt :
Therefore, it is important to find out if these symptoms are cardiac-related. The prevalence of chest pain in a normal population has been reported to be from 7% to 14%22-24 with a musculoskeletal cause varying from 36% to nearly 50% and cardiovascular cause from 12% to 18%.25,26 Moreover, 1 of 5 of the adults with OI also reported dyspnoea, which might be an early sign of a coronary artery disease in the absence of either angina or ECG changes, which indicate ischemia.27
Osteogenesis imperfecta (OI), also known as brittle bone disease or Lobstein syndrome, is a congenital bone disorder characterized by brittle bones that are prone to fracture. People with OI are born with defective connective tissue in most cases secondary to a deficiency of type-I collagen, which represents approximately 75% of total collagen in the adult myocardium. The purpose of our study was to assess the prevalence of cardiomyopathy, electrocardiogram (ECG) abnormalities, and cardiovascular symptoms among patients with OI.
We studied 99 adults with OI from the national OI registry in Norway. Patients were divided into type I, III, and IV, and 52 control subjects. History and physical examination, ECG, and echocardiographic parameters of left ventricular (LV) and right ventricular (RV) systolic and diastolic function were obtained.
ECG abnormalities and cardiac symptoms were more common among patients with OI. RV and LV systolic peak velocity were significantly lower and diastolic mitral tricuspid valve wave and early diastolic tissue Doppler velocity ratio increased in the OI group compared with the control subjects; 5.7 ± 1.2 vs 6.3 ± 1.2 cm/s (P < 0.05) and 8 ± 1.8 vs 9.5 ± 1.4 cm/s (P < 0.05) and 9.8 ± 2.6 vs 7.4 ± 2.0 (P < 0.05) and 8.6 ± 3.3 vs 6.1 ± 1.4, respectively. In multivariate analysis OI was found to be an independent risk factor for RV systolic and diastolic dysfunction.
Cardiac symptoms and ECG changes are common among patients with OI. Our study findings suggest RV and LV systolic and diastolic function to be impaired in patients with OI compared with normal individuals. In multivariate analysis, however, OI was an independent predictor only of reduced RV systolic and diastolic function.
L’osteogénèse imparfaite (OI), également connue comme la fragilité osseuse héréditaire ou le syndrome de Lobstein, est une maladie osseuse congénitale caractérisée par des os cassants qui sont sujets aux fractures. Les personnes atteintes d’OI sont nées avec des tissus conjonctifs défectueux dans la plupart des cas secondaires à une anomalie de production du collagène de type 1, qui représente approximativement 75 % du collagène total du myocarde de l’adulte. Le but de notre étude était d’évaluer la prévalence de la cardiomyopathie, des anomalies l’électrocardiogramme (ECG) et des symptômes de maladies cardiovasculaires chez les patients atteints d’OI.
Nous avons étudié 99 adultes atteints d’OI inscrits au registre national d’OI de la Norvège. Les patients étaient divisés selon le type 1, III et IV, et 52 sujets témoins. L’anamnèse et l’examen physique, l’ECG et les paramètres échocardiographiques de la fonction systolique et diastolique du ventricule gauche (VG) et du ventricule droit (VD) ont été obtenus.
Les anomalies à l’ECG et les symptômes cardiaques étaient plus fréquents chez les patients atteints d’OI. Les pics de vélocité systolique du VD et du VG étaient significativement plus faibles et le ratio de l’onde diastolique des valves tricuspide et mitrale et de la vélocité diastolique précoce au Doppler tissulaire augmentait dans le groupe atteint d’OI comparativement aux sujets témoins; 5,7 ± 1,2 vs 6,3 ± 1,2 cm/s (P < 0,05) et 8 ± 1,8 vs 9 5 ± 1,4 cm/s (P < 0,05) et 9,8 ± 2,6 vs 7,4 ± 2,0 (P < 0,05) et 8,6 ± 3,3 vs 6,1 ± 1,4, respectivement. Dans l’analyse multivariée, l’OI s’était avérée un facteur de risque indépendant de la dysfonction systolique et diastolique du VD.
Les symptômes cardiaques et les changements observés à l’ECG sont fréquents chez les patients atteints d’OI. Les conclusions de notre étude suggèrent que les fonctions systolique et diastolique du VD et du VG sont détériorés chez les patients atteints d’OI comparativement aux individus normaux. L’analyse multivariée a toutefois démontré que l’OI était seulement un prédicteur indépendant de la diminution des fonctions systolique et diastolique du VD.
Meta-analysis of prognostic implications of dyspnea versus chest pain in patients referred for stress testing
2014, American Journal of Cardiology
Citation Excerpt :
These findings include consistent observations among patients undergoing exercise electrocardiography, stress echocardiography, and stress radionuclide imaging studies. Previous work has suggested that dyspnea is likely to represent an anginal equivalent in patients with known CAD.5,6 If so, a high frequency of inducible myocardial ischemia would be expected among patients presenting with dyspnea, but the published literature is inconsistent with respect to the incidence of ischemia among patients with dyspnea.
Previous studies have suggested that patients with dyspnea referred for stress testing have high mortality. However, it is not clear whether this is explained by high rates of ischemia. The aim of the present study was to evaluate the incidence of ischemia in patients with dyspnea compared with patients with chest pain referred for stress testing and assess the outcomes of such patients. We systematically searched the electronic databases, MEDLINE, PubMed, EMBASE, and the Cochrane Library, until December 2012 to identify studies of patients with known or suspected coronary artery disease undergoing stress testing. We extracted data on group-specific incidence of stress-induced ischemia and all-cause mortality. In our analyses, we identified and included 6 studies that evaluated a total of 5,753 patients with dyspnea and 24,491 patients with chest pain as the clinical indication for stress testing. There was no statistically significant difference in the incidence of ischemia on stress imaging in patients with dyspnea compared with patients with chest pain (37.4% vs 30.2%, odds ratio 1.43, 95% confidence interval 0.99 to 2.06, p = 0.06). However, during the follow-up period, patients with dyspnea had higher all-cause mortality rates compared with patients with chest pain (annual mortality 4.9% vs 2.3%), with odds ratio of 2.57 (95% confidence interval 1.75 to 3.76, p <0.001). In conclusion, in patients undergoing stress testing, those evaluated for dyspnea had a significant increase in all-cause mortality but did not have higher rates of ischemia compared with patients presenting with chest pain. Clinicians evaluating patients with self-reported dyspnea should be aware that these patients represent a high-risk group with increased risk of mortality.
Predictors of ischemia in patients referred for evaluation of exertional dyspnea: A stress echocardiography study
2013, Journal of the American Society of Echocardiography
Citation Excerpt :
Similarly, in a study by Abidov et al.,9 80% of patients with established CAD had abnormal myocardial perfusion results compared with 19% of patients without known CAD. Therefore, in this subpopulation of patients, exertional dyspnea could be truly an angina equivalent, as previously described.1,10 On the contrary, in patients without known CAD and normal resting wall motion, the likelihood of positive stress test results was very low (<4%), despite a relatively high prevalence of diabetes mellitus (36%) and burden of traditional risk factors (1.5 per patient) (Figure 1).
There are conflicting data on the incidence of ischemia by stress echocardiography in patients referred for dyspnea without accompanying chest pain.
A total of 311 consecutive patients with exertional dyspnea (without chest pain) referred to the echocardiography lab for ischemia evaluation from August 2008 to March 2012 were evaluated. Exercise by Bruce protocol or dobutamine stress echocardiography was performed. Resting left ventricular ejection fraction and segmental wall motion abnormalities were assessed. Multivariate logistic regression analysis was used to identify independent predictors of ischemia on stress echocardiography.
The mean age was 61 years (range, 20–96 years), with 196 women (63%). Exercise stress was performed in 114 patients (37%); the rest of the patients underwent dobutamine stress. The patient population had a high burden of obesity, diastolic dysfunction, and pulmonary hypertension. Thirty patients (10%) had evidence of stress-induced ischemia (nine [8%] with exercise and 21 [11%] with dobutamine). In multivariate analysis, male gender (odds ratio, 2.8; P = .03), history of coronary artery disease (odds ratio, 3.5; P = .02), and resting wall motion abnormalities (odds ratio, 16.6; P < .01) were independent predictors of inducible ischemia.
The incidence of stress-induced ischemia is low in patients referred for stress echocardiography with exertional dyspnea (without chest pain). Ischemia is more likely to be present in men with histories of coronary artery disease and resting wall motion abnormalities.
The value of stress single photon emission computed tomography in patients without known coronary artery disease presenting with dyspnea
2006, American Heart Journal
Dyspnea is a complex system with multiple etiologies, including myocardial ischemia (“anginal equivalent”). Few studies have examined the utility of stress testing to detect coronary artery disease in this setting. The purpose of this study was to examine the prevalence, severity, and prognostic value of perfusion defects detected by stress single photon emission computed tomography (SPECT) imaging in patients with dyspnea.
SPECT imaging was performed in 1864 patients (age 65.8 ± 10.2 years, 52% male, 23% diabetic, 89% overweight/obese) without known coronary artery disease referred for evaluation of dyspnea. Dyspnea was rated mild, moderate, or severe. SPECT scans were categorized low, intermediate, or high risk. The associations of stress SPECT imaging results with clinical variables and mortality were analyzed.
An abnormal perfusion SPECT image was present in 45% of patients and a high-risk scan in 11%. Male sex, diabetes, and clinical severity of dyspnea were the strongest predictors of both an abnormal and high-risk SPECT scan. A high-risk scan was present in 5% of nondiabetic women with mild dyspnea versus 22% of diabetic men with dyspnea of any severity. At 10 years, survival by SPECT scan category was low risk 75%, intermediate risk 68%, and high risk 53% (P < .001).
In this population of older overweight patients referred for evaluation of dyspnea, there was a high prevalence of abnormal (45%) and high-risk (11%) SPECT scans. High-risk scans were associated with much worse 10-year survival.
The diagnosis of heart disease by clinical assessment alone
2002, Disease-a-Month
Citation Excerpt :
Although chest pain is the classic symptom in the great majority of patients, it is by no means present in all. In some patients, dyspnea (secondary to an elevated left ventricular [LV] filling pressure [diastolic dysfunction] and/or transient ischemic mitral regurgitation [MR]) or extreme fatigue, weakness, and dizziness (due to a reduced cardiac output [LV systolic dysfunction] or tachyarrhythmia/bradyarrhythmia), instead of pain, may be a manifestation of myocardial ischemia (″anginal equivalent”).69 Chest pain may be absent (″silent ischemia”) in as many as 25% or more of patients, especially in those with diabetes mellitus, in whom pain perception may be altered by neuropathy (″defective warning system”); in elderly patients, in whom such atypical symptoms as confusion, lightheadedness, syncope, shortness of breath, or gastrointestinal upset may be the presenting complaint; or in those in the postoperative state recovering from anesthesia and/or receiving analgesics.70

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^☆: The British Regional Heart Study is a British Heart Foundation Research Group and is also supported by the Medical Research Council and the Department of Health, London. The Chest Heart and Stroke Association supports the work on the respiratory aspects of this study. The electrocardiographic studies are supported by the Scottish Home and Health Department and the Greater Glasgow Health Board.

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Breathlessness, angina pectoris and coronary artery disease☆

Abstract

J Chronic Dis

Relationship between dyspnea and chest pain in ischaemic heart disease

Acta Med Scand

The diagnosis of ischaemic heart pain and intermittent claudication in field surveys

Bull WHO

British Regional Heart Study: cardiovascular risk factors in middle-aged men in 24 towns

Br Med J

Respiratory Function, Smoking and Coronary Heart Disease in British Men