Stable Angina PectorisEpidemiology and prognosisIs it improving?

GK Efthimiadis, MD

William Harvey (1578 –1657)

third circulation

de circulo sanguinis

in corde

Classic description of angina pectoris

William Heberden

Royal College

of Physicians

1768

Angina Pectoris

Angina (αγχόνη): ―strangling‖ or infection of the throat

Pectoris: pectus (chest)

Angina Pectoris (1700-1800)

Unknown pathogenesis

Treatment: bloodletting, tincture of opium, bed rest

Caleb Parry (1799) :

Coronary-artery ossification

Predominantly in men ≥50 years

Angina Pectoris

….is excited more especially upon walking up hill, and after a meal

...accompanied with a sensation, which threatens instant death if the motion is persisted

…on stopping, the distress immediately abates

Angina Pectoris (1800-1900)

1844: cardiac catheterized in animals (Claude Bernard) 1867:Brunton L. On the use of nitrite amyl in angina pectoris.

Lancet 1879:coronary thrombosis ―secondary to sclerotic changes in

the coronaries 1889: occlusion of a coronary artery in the dog:―quivering‖

(VF) of the ventricles-rapidly fatal. 1910: total bed rest 1919: electrocardiography 1920: first human cardiac catheterization (Forssman — on

himself ) standard of care until the mid-20th century.

Egyptian princess Ahmose-Meryet-Amon (Thebes, 1580 and 1550 BC)First Person in Human History With Diagnosed Coronary Artery Disease Ancient Egyptian PrincessScience Daily (May 17, 2011)

Angina Questionnaire ItemsRose GA et al. Cardiovascular

Survey Methods. 2nd ed. Switzerland: WHO;1982.

1. Have you ever had any pain or discomfort in your chest? (yes)

2. Do you get it when you walk uphill or hurry?3. Do you get it when you walk at an ordinary pace

on the level?If the answer to question 2 or question 3 is ―yes,‖ then proceed toquestion 4

4. What do you do if you get it while walking? (stop or slow down)

5. If you stand still what happens? (relieved)6. How soon? (10 minutes or less)7. Location? (central chest or left arm)

Typical Progression of Coronary Atherosclerosis.

Abrams J. N Engl J Med 2005;352:2524-2533.

Angina/MI as first manifestation of coronary artery disease (Rochester, Minn1960-1980)

MI/SD: 66% in men (m age 72y), 54% in women (62y)

Angina pectoris:

34% in men (m age 60y)

incidence of MI/Death in 20 y 60%

46% in women (m age 67y)

incidence of MI/Death in 20 y 40% JAMA. 1993;269:2392-2397

Prevalence of angina pectoris

(total cases/population)

Women: 45-54-y 0.1–1%, 65-74-y 10–15%

Men: 45-54-y 2-5%, 65-74-y 10–20%

Europe: 20,000–40,000/million

High prevalence of angina pectoris in women?

Small epicardial arteries

Angina with normal coronaries

Higher heart rate

Gestation diabetes and hypertension

YANO K, UEDA S. CORONARY HEART DISEASE IN HIROSHIMA, JAPAN: ANALYSIS OF THE DATA AT THE INITIAL EXAMINATION, 1958-1960. Yale J Biol Med. 1963 Jun;35:504-22

Incidence (new cases per year/population): 0.5%

Date of download: 11/25/2012Copyright © 2012 American Medical

Association. All rights reserved.

From: Incidence and Prognostic Implications of Stable Angina Pectoris Among Women and Men

JAMA. 2006;295(12):1404-1411. doi:10.1001/jama.295.12.1404

CI indicates confidence interval. The size of the data markers represents the number of angina cases.*Annual risk per 100

population, using estimated total population of Finland in 1996. Because the case definitions of angina are mutually exclusive, the

same population denominator was used for each.†Age-standardized to the combined (women and men) population.

Figure Legend:

Date of download: 11/25/2012Copyright © 2012 American Medical

Association. All rights reserved.

From: Incidence and Prognostic Implications of Stable Angina Pectoris Among Women and Men

JAMA. 2006;295(12):1404-1411. doi:10.1001/jama.295.12.1404

CI indicates confidence interval.

Figure Legend:

PROGNOSIS

Curtin RG. Statistics of Sixty Deaths from Angina Pectoris. Trans Am Climatol Assoc. 1907;23:253-61.

Curtin RG. Statistics of Sixty Deaths from Angina Pectoris. Trans Am Climatol Assoc. 1907;23:253-61.

Prognosis (1970-1990)

Mortality rates for men with Rose questionnaire angina

2.6 -17.6/1000 patient-years (1970-1990)

(European data) Lampe FC, Morris RW, Whincup PH, Walker M, Ebrahim S, Shaper

AG. Is the prevalence of coronary heart disease falling in British men? Heart. 2001;86:499–505.

WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease. monica Lancet 1999;353:1547–1557.

Prognosis (1970-1990)

Initial clinical presentation of stable angina 2-year: MI and CHD death 14.3 and 5.5% in men 6.2 and 3.8% in women Framingham Heart Study. Am J Cardiol

1972;29:154–163. Reunanen A. Prognosis after the onset of coronary heart

disease. An investigation of differences in outcome between the sexes according to initial coronary disease presentation. Circulation 1993;88:2548–2555.

Prognosis in recent years

Data from clinical trials:

antianginal therapy

revascularization (selected nature of the populations)

Mortality: 0.9–1.4%/year

Incidence of non-fatal MI:

0.5% (INVEST)

2.6% (TIBET)

Prognosis in recent years

More aggressive investigation and treatment

Important: select those patients with a less severe form of disease

good outcome

avoiding unnecessary procedures

Risk stratification

Annual cardiovascular mortality

2%: high risk

1%: low risk

1–2%: intermediate risk

Risk stratification

by clinical evaluation

by response to stress testing

by ventricular function

by coronary anatomy

Predictors of prognosis

Conventional risk factors for CAD

Hypertension

Hypercholesterolaemia

Diabetes

Smoking

Predictors of prognosis

LV function (strongest)

Left main disease

Three-vessel disease

Proximal LAD

Myocardial revascularization

Age- and Sex-Adjusted Incidence Rates of Acute Myocardial Infarction, 1999 to 2008

Yeh RW et al. N Engl J Med 2010;362:2155-2165

Decline in Deaths from Cardiovascular Disease in Relation to Scientific Advances.

Nabel EG, Braunwald E. N Engl J Med 2012;366:54-63