Angina pectoris: Has the cornerstone of symptomatic coronary artery disease been moved?

Abstract

But there is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, which deserves to be mentioned more at length. The seat of it and sense of strangling, and anxiety with which it is attended, may make it not improperly be called angina pectoris. They who are afflicted with it are seized while they are walking (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue; but the moment they stand still this uneasiness vanishes.William Heberden 1768 (1-3)A classical history of angina pectoris has long been considered to be a symptom of myocardial ischemia and, as such, a predictor of the presence of significant coronary artery disease. The work by Høilund-Carlsen et al (pages 641-647 of the current issue of the Journal) challenges this cornerstone of care.This work provides an interesting window into the correlation of clinical history with the presence of angiographic disease. This study was a substudy of a larger prospective study that looked at myocardial perfusion scintigraphy (MPS) as a gatekeeper for coronary angiography (CA) in patients referred for angiography with angina pectoris and possible coronary artery disease.The data collected for this study are unique. At the time of the study, MPS was not a routine part of the work-up of patients with suspected coronary artery disease in Denmark. The patients were isolated on the island of Funen. Patients were sent directly for angiography from local general practitioners or through local hospitals. Before angiography, they received MPS, and only after the angiogram were the results available to the investigator or clinician. This local practice variation enabled a comparison of MPS with CA in a group of patients who would not normally be selected for angiography based on the results of the MPS study, thus eliminating the effect of 'referral' or 'work-up' bias on the correlation of MPS and CA. Work-up bias has been examined in the literature, and the overall effect is that a greater number of angiograms are performed in patients with abnormal scans. This increases the sensitivity and reduces the specificity of the test being evaluated -in this case, the MPS (4,5).This study has a number of companion publications (6-8); the purpose of the original study was to compare patient findings on MPS with those found on CA. In this population, the overall sensitivity of MPS was found to be 75% and the specificity was 79% (8). At publication, these results were attributed to the absence of a referral or work-up bias.The focus of the current publication was the correlation of clinical features to the angiogram. Three clinical assessment scales were used to classify patients undergoing angiography. The subgroups of patients who were thought to have a high probability of disease were then segregated, and the correlation to significant angiographic cor...