What is the clinical evidence from this study?

Study design: Cohort. Population: Suspected stable angina pectoris (n=7794). Intervention: Typical chest pain symptoms vs. Atypical chest pain symptoms. Primary outcome: Coronary death or acute coronary syndromes (HR 2.30, 95% CI 1.70-3.11, p=<0.001).

September 22, 2008Open Access

Presentation of stable angina pectoris among women and South Asian people

Q: What are the key findings of this study?

Typical chest pain symptoms were associated with a significantly higher risk of coronary death or acute coronary syndromes among women (HR 2.30) compared to atypical symptoms.

MZMichele ZamanImperial College Healthcare NHS Trust CJCornelia JunghansImperial College London NSNeha SekhriQueen Mary University of London

Key Result

Typical chest pain symptoms were associated with a significantly higher risk of coronary death or acute coronary syndromes among women (HR 2.30) compared to atypical symptoms.

Study Design

Type

Cohort (n=7,794)

Multicenter

Yes

Structured PICO

Does the presentation of typical versus atypical chest pain symptoms predict coronary outcomes and influence clinical management differently among women and South Asian patients compared to men and white patients?

Population

7,794 patients (46.9% female) with recent-onset chest pain suspected to be stable angina pectoris, followed for a mean of 3.05 years.

Exposure

Typical chest pain symptoms (defined as having 3 or more of the following characteristics: constricting quality, located centrally or left-sided, lasting seconds to 15 minutes, and provoked by exercise)

Comparator

Atypical chest pain symptoms (defined as having 2 or fewer characteristics of typical pain)

Outcome

Composite of death from coronary artery disease or hospital admission for acute coronary syndrome (acute myocardial infarction and unstable angina)hard clinical

Typical chest pain symptoms are a strong predictor of adverse coronary outcomes in women and South Asian patients, yet these groups remain less likely to receive invasive management compared to men and white patients.

Main Result

Hazard Ratio: 2.3 (95% CI 1.7–3.11)

p-value: p=<0.001

Limitations

Recorded patient history may have been biased by knowledge of exercise electrocardiography findings.
South Asian ethnic background encompasses diverse groups with potentially different cardiovascular risk profiles.
Data were not available on the findings of angiography.
Actual words used by patients, their meaning and context were not reported.

Abstract

BACKGROUND: There is speculation that women and South Asian people are more likely than men and white people to report atypical angina and that they are less likely to undergo invasive management of angina. We sought to determine whether atypical symptoms of angina pectoris in women and South Asians impacted clinically important outcomes and clinical management. METHODS: We prospectively identified 2189 South Asian people and 5605 white people with recent-onset chest pain at 6 chest-pain clinics in the United Kingdom. We documented hospital admissions for acute coronary syndromes, coronary deaths as well as coronary angiography and revascularization procedures. RESULTS: Atypical chest pain was reported by more women than men (56.5% vs 54.5%, p < 0.054) and by more South Asian patients than white patients (59.9% vs 52.5%, p < 0.001). Typical symptoms were associated with coronary death or acute coronary syndromes among women (hazard ratio HR 2.30, 95% CI 1.70-3.11, p < 0.001) but not among men (HR 1.23, 95% CI 0.96-1.57, p = 0.10). Typical symptoms were associated with coronary outcomes in both South Asian and white patients. Among those with typical symptoms, women (HR 0.76, 95% CI 0.63-0.92, p = 0.004) and South Asian patients (HR 0.52, 95% CI 0.41-0.67, p < 0.001) were less likely than men and white patients to receive angiography. INTERPRETATION: Compared to those with atypical chest pain, women and South Asian patients with typical pain had worse clinical outcomes. However, sex and ethnic background did not explain differences in the use of invasive procedures.

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