Long-term prognosis of angina pectoris in a general population – insights from the SCAPIS cohort

Background Angina pectoris remains a common clinical manifestation of chronic coronary syndrome, yet contemporary prognostic data from the general population are lacking, particularly in relation to coronary pathology. Purpose To evaluate the long-term prognostic importance of angina pectoris, in relation to coronary artery disease (CAD) severity, determined by coronary computed tomography angiography (CCTA) in a randomly selected general population-based cohort. Methods This cohort study included 24, 176 participants (aged 50-64 years) from the Swedish CArdioPulmonary bioImage Study (SCAPIS) who completed the Rose Angina Questionnaire and had valid CCTA without prior myocardial infarction (MI), heart failure, or coronary revascularisation. Participants were categorised as having angina or no angina, and according to coronary findings as no coronary atherosclerosis, non-obstructive CAD (NO-CAD; <50% stenosis), or obstructive CAD (O-CAD; ≥50% stenosis). Cox regression models evaluated associations between angina and MI or coronary death and major adverse cardiac events (MACE; MI, coronary revascularisation, heart failure hospitalisation, coronary or heart failure death), including stratification by CAD categorisation and sequential multivariable adjustment, including sociodemographic and medical background variables, CAD severity and plaque burden. Results Angina was present in 3.0% of participants. Over a median follow-up time of 7.7 years, 293 primary events occurred. Angina was associated with a higher incidence of MI or coronary death (2.9% vs. 1.2%; HR 2.50, 95% CI 1.60–3.90), with increasing event rates across CAD severity categories and no evidence of interaction between symptoms and coronary findings. After multivariable adjustment, the association remained significant (HR 1.65, 95% CI 1.04–2.63). Similar patterns were observed for MACE (adjusted HR 2.34, 95% CI 1.73–3.16). Conclusion In this large contemporary population study, angina pectoris independently predicted adverse cardiovascular outcomes beyond coronary pathology assessed by CCTA. These findings highlight functional coronary microvascular disorders as contributing pathogenesis in angina pectoris and suggest that symptom assessment remains clinically relevant in modern cardiovascular risk stratification, providing incremental prognostic information.