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Chest pain on questionnaire and prediction of major ischaemic heart disease events in men.

OBJECTIVE
To examine the prediction of major ischaemic heart disease events by questionnaire-assessed chest pain and other symptoms.


DESIGN
Population-based prospective study.


SUBJECTS
7735 randomly selected men, aged 40-59 years at entry.


METHODS
Symptoms and history of diagnosed ischaemic heart disease were ascertained by administered questionnaire at baseline. Follow-up was for an average of 14.7 years, for first major ischaemic heart disease event.


RESULTS
During follow-up, 969 men had a major ischaemic heart disease event. 'Definite' angina (chest pain fulfilling all WHO criteria) and 'possible' angina (exertional chest pain without all other WHO criteria) were associated with similar ischaemic heart disease outcome, and a single combined angina category was used. In the whole cohort, the relative risks (95% CI) of a major ischaemic heart disease event were 2.03 (1.61, 2.57) for angina only, 2.13 (1.72, 2.63) for possible myocardial infarction only and 4.50 (3.57, 5.66) for angina plus possible myocardial infarction, compared to no chest pain. The relative risk for recall of an ischaemic heart disease diagnosis was 3.98 (3.36, 4.71). Only 33% of men with angina or possible myocardial infarction symptoms recalled a previous ischaemic heart disease diagnosis. In men without recall of an ischaemic heart disease diagnosis (in whom 82% of events during follow-up occurred), chest pain symptoms remained predictive of major ischaemic heart disease events with relative risks (95% CI) of 1.69 (1.27, 2.24) for angina only, 1.49 (1.12, 1.97) for possible myocardial infarction only and 2.55 (1.44, 4.53) for angina plus possible myocardial infarction. 'Other chest pain' increased risk of a major ischaemic heart disease event by 1.19 (1.01, 1.40) compared to no chest pain. Symptoms of breathlessness or calf pain on walking increased ischaemic heart disease risk in men with 'other chest pain' and in men without chest pain, but had no further effect on ischaemic heart disease risk in men with symptoms of angina or possible myocardial infarction.


CONCLUSIONS
In defining angina by chest pain questionnaire, the exertional component is the crucial criterion. When using questionnaire-assessed symptoms to determine ischaemic heart disease risk, information on previous ischaemic heart disease diagnoses should be taken into account. The majority of men with angina or possible myocardial infarction symptoms do not have a diagnosis of ischaemic heart disease, but they remain at significantly increased risk of a major ischaemic heart disease event. The value of breathlessness and calf pain on walking in stratifying ischaemic heart disease risk is restricted to men with 'other chest pain' or no chest pain.