Original articles
Presentation, management and course of angina and suspected angina in primary care

https://doi.org/10.1016/S0022-3999(98)00102-0Get rights and content

Abstract

Previous surveys may have underestimated both prevalence and incidence of ischemic heart disease in general practice. Case identification is difficult, as many patients presenting with chest pain turn out not to have ischemic heart disease, although their outcome is unclear otherwise. In this work we aimed to: (1) estimate prevalence and incidence of angina in one Oxford general practice; (2) describe the processes of assessment, investigation, and management of suspected angina; and (3) describe the 2-year symptomatic and functional outcome of angina patients, compared with patients whose provisional diagnosis of suspected ischemic heart disease (IHD) was not subsequently sustained (NCCP). A retrospective survey of patients was undertaken (aged 45–74 years) by hand searching paper and electronic medical records to find, as of 1 January 1992, all patients in the practice with continuing treatment of angina diagnosed before 1989, or those having a new diagnosis of angina being assessed (suspected angina) in the 3 years 1989–1991. Two years later, a postal questionnaire survey compared the symptomatic and functional outcome of confirmed IHD and NCCP. On 1 January 1992, the diagnosis of angina was recorded in the notes of 11.1% of patients aged 45–74 years, and the diagnosis was considered correct in 7.4%. Over a 3-year period, 129 people were suspected of suffering from angina, but in 71 (55%) the diagnosis was not confirmed; 76 (59%) were either referred to a specialist out-patient clinic or had an emergency admission. A 2-year follow-up found that similar proportions of patients with angina and noncardiac chest pain had a poor outcome in terms of symptoms, mental state, quality of everyday life, and continuing consultation. The clinical burden of ischemic heart disease in general practice has been underestimated by earlier methodological approaches using less complete ascertainment strategies. The adequacy of current diagnostic and management arrangements for patients with suspected angina merits review, at both the primary and secondary care levels.

Introduction

Cardiologists [1] and others have proposed guidelines for the management of suspected angina in primary care, including detailed criteria for specialist referral. In practice, however, GPs seem to refer only a minority of such patients, and hold divergent and contradictory opinions about management [2].

Little is known about incidence, prevalence, and management of angina in primary care. Surveys have reported an incidence of 1.1 per 1000 in middle-aged men aged 30–59 years [3]. A survey of prescriptions [4] suggested a prevalence of 1.5% in the total population; Fry reported a prevalence of 5 per 1000 in his general practice [5]. A recent estimate from subjects referred to an open-access ECG service found an incidence of only 1.13 per 1000 in men and 0.53 per 1000 in women aged 31–70 years [6].

However, only a portion of chest pain presentations in primary care suspected of being due to angina (e.g., 12% [7]) have been confirmed as being due to ischemic heart disease, and very little is known about the outcome of pain that is noncardiac. Hospital series indicate that “noncardiac chest pain” (NCCP) patients have a good prognosis in terms of mortality and cardiac morbidity and are usually reassured and discharged [8]. However, many continue to experience long-term symptoms and disability 9, 10.

In the present study, we aimed to:

  • 1.

    Estimate prevalence and incidence of angina.

  • 2.

    Describe the processes of assessment, investigation, and management of suspected angina.

  • 3.

    Describe the 2-year symptomatic and functional outcome of angina patients, compared with patients whose provisional diagnosis of suspected ischemic heart disease (IHD) was not subsequently sustained (NCCP).

Section snippets

Method

The study was conducted from January to March 1992 at a four-partner, 6600-patient, urban Oxford teaching practice serving a mainly industrial population. The practice has used a VAMP computer system since January 1989 for all prescribing, with a corresponding history entry; paper A4 records were also maintained.

Results

Results are presented separately for patients with: confirmed angina (i.e., those in whom the diagnosis of angina was believed to be correct at the time of the survey); patients who newly presented with suspected angina in the 3-year period 1989–1991; and for patients found to have noncardiac chest pain.

Discussion

Our study raises important general issues about the identification and management of both angina and noncardiac chest pain in general practice, and the role of specialist services. Whereas there are advantages of a detailed study of a single general practice, there are also limitations. Practices vary widely, and findings in a single health center with academic links must be interpreted with caution. Nonetheless, there is no reason to believe that the frequency of angina and other chest pain

Acknowledgements

We are grateful to Dr. E. Barclay for the collection of the data from the notes. We are grateful to the the staff at Hollow Way Surgery for their cooperation with the study. This work was funded by a grant from the British Heart Foundation.

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