The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK

Prevalence and factors associated with undiagnosed and uncontrolled heart disease: A study based on self-reported chronic heart disease and symptom-based angina pectoris among middle-aged and older Indian adults

BACKGROUND

This study aimed to examine the prevalence of heart diseases and angina pectoris and associated factors among middle-aged and older Indian adults. Additionally, the study examined the prevalence and associated factors of undiagnosed and uncontrolled heart disease among middle-aged and older adults based on self-reported chronic heart disease (CHD) and symptom-based angina pectoris (AP).

METHODS

We used cross-sectional data from the first wave of the Longitudinal Ageing Study of India, 2017-18. The sample consists of 59,854 individuals (27, 769 males and 32,085 females) aged 45 years and above. Maximum likelihood binary logistic regression models were employed to examine the associations between morbidities, other covariates (demographic factors, socio-economic factors and behavioral factors) and heart disease and angina.

RESULTS

A proportion of 4.16% older males and 3.55% older females reported the diagnosis of heart diseases. A proportion of 4.69% older males and 7.02% older females had symptom-based angina. The odds of having heart disease were higher among those who were hypertensive and who had family history of heart disease, and it was higher among those whose cholesterol levels were higher. Individuals with hypertension, diabetes, high cholesterol and family history of heart disease were more likely to have angina than their healthy counterparts. The odds of undiagnosed heart disease were lower but the odds of uncontrolled heart disease were higher among those who were hypertensive than non-hypertensive individuals. Those having diabetes were less likely to have undiagnosed heart disease while among the diabetic people the odds of uncontrolled heart disease were higher. Similarly, higher odds were observed among people with high cholesterol, having stroke and also among those who had a history of heart disease than their counterparts.

CONCLUSIONS

The present study provided a comparative prevalence of heart disease and agina and their associations with chronic diseases among middle-aged and older adults in India. The higher prevalence of undiagnosed and uncontrolled heart disease and their risk factors among middle-aged and older Indians manisfest alarming public health concerns and future health demand.

Factors related to health-related quality of life in patients with acute coronary syndrome in West Java, Indonesia: A correlational study

Background

Although acute coronary syndrome impacts patients' health-related quality of life, a dearth of studies explore this issue in Indonesia. Thus, understanding factors associated with health-related quality of life among patients with acute coronary syndrome is a necessity.

Objective

This study aimed to examine the relationships between age, pain, dyspnea, functional status, self-efficacy, social support, and health-related quality of life in patients with acute coronary syndrome in West Java, Indonesia.

Methods

This study employed a descriptive correlational study involving 186 patients with acute coronary syndrome purposively selected in the outpatient clinics of the top referral public hospital. Data were collected in 2020 using validated instruments: Rose Questionnaire for Angina (RQA), Rose Dyspnea Scale (RDS), Seattle Angina Questionnaire (SAQ), General Self-efficacy Scale (GSE), ENRICHD Social Support Instrument (ESSI), and MacNew Health-Related Quality of Life. Data were analyzed using descriptive statistics and Spearman-rank correlation.

Results

Overall, the health-related quality of life in patients with acute coronary syndrome was high (Mean = 4.97, SD = 0.92), including in its subscales: emotional (Mean = 4.94, SD = 0.88), physical (Mean = 5.07, SD = 1.12), and social (Mean = 5.05, SD = 1.55) subscales. Significant factors related to health-related quality of life were pain (r = 0.296, p <0.001), functional status (r = 0.601, p <0.001), dyspnea (r = -0.438, p <0.001), and self-efficacy (r = 0.299, p <0.001). Meanwhile, age and social support had no significant relationships with health-related quality of life (p = 0.270, p = 0.059). Interestingly, social support was significantly correlated with the emotional subscale of health-related quality of life (r = 0.156, p = 0.034).

Conclusion

Functional status, pain, and self-efficacy were positively correlated with health-related quality of life, while dyspnea had a negative association. This finding serves as basic information for nurses and other healthcare professionals to consider the related factors identified in this study to improve nursing interventions in order to increase health-related quality of life among patients with acute coronary syndrome.

Disparities in Reporting a History of Cardiovascular Disease Among Adults With Limited English Proficiency and Angina

IMPORTANCE

Individuals with limited English proficiency (LEP) may be unaware of underlying cardiovascular disease (CVD) owing to a lack of diagnostic testing or poor communication with health care practitioners.

OBJECTIVE

To evaluate whether participants with anginal symptoms and LEP would be less likely to report a history of CVD compared with those without LEP.

DESIGN, STUDY, AND PARTICIPANTS

This population-based cross-sectional study combined data from 5 National Health and Nutrition Examination Survey (NHANES) cycles conducted from 2007 to 2016. Each cycle includes an interview that collects demographic, dietary, and health-related data as well as a medical examination component in which physiological measurements are taken. All NHANES participants aged 40 years or older who took the Rose questionnaire were included. Data were analyzed from September 2020 to April 2021.

EXPOSURES

LEP was defined as a participant receiving the survey in a non-English language or by interpreter.

MAIN OUTCOMES AND MEASURES

The 7-item Rose questionnaire assessed the presence of anginal symptoms. Self-reported CVD was defined as history of heart failure, coronary heart disease, angina pectoris, or myocardial infarction. The association between LEP status and self-reported CVD among those with anginal symptoms was determined in multivariable-adjusted models. All analyses were weighted per NHANES analytic protocols.

RESULTS

Among 19 320 participants (mean [SD] age, 57.8 [11.8] years; 9344 [47.2%] male; 4145 [10.6%] Black; 2743 [6.3%] Mexican American; 2111 [4.6%] other Hispanic; 8386 [71.6%] White; and 1935 [6.9%] other race), 583 (3.0%) reported anginal symptoms. Of these, most were non-LEP (484 [96.1%]), women (344 [62.1%]), White (251 [66.8%]), and did not report having CVD (347 [62.8%]). Among those with angina, 73 of 99 respondents with LEP (79.0%) reported not having a history of CVD, compared with 274 of 484 without LEP (61.4%; P = .002). Participants with LEP had 2.8-fold higher odds of not reporting a history of CVD compared with participants without LEP (odds ratio, 2.77; 95% CI, 1.38-5.55; P = .005).

CONCLUSIONS AND RELEVANCE

Among NHANES participants reporting anginal symptoms, participants with LEP were more likely not to report having CVD. This discrepancy may be because of higher rates of undiagnosed CVD or lower awareness of such diagnoses among individuals with LEP. Our findings highlight the relevance of communication strategies for individuals with LEP to provide effective intervention and treatment for CVD prevention.

Computed Tomography Screening for Early Lung Cancer, COPD and Cardiovascular Disease in Shanghai: Rationale and Design of a Population-based Comparative Study

RATIONALE AND OBJECTIVES

To describe the rational and design of a population-based comparative study. The objective of the study is to assess the screening performance of volume-based management of CT-detected lung nodule in comparison to diameter-based management, and to improve the effectiveness of CT screening for chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD), in addition to lung cancer, based on quantitative measurement of CT imaging biomarkers in a Chinese screening setting.

MATERIALS AND METHODS

A population-based comparative study is being performed, including 10,000 asymptomatic participants between 40 and 74 years old from Shanghai urban population. Participants in the intervention group undergo a low-dose chest and cardiac CT scan at baseline and 1 year later, and are managed according to NELCIN-B3 protocol. Participants in the control group undergo a low-dose chest CT scan according to the routine CT protocol and are managed according to the clinical practice. Epidemiological data are collected through questionnaires. In the fourth year from baseline, the diagnosis of the three diseases will be collected.

RESULTS

The unnecessary referral rate will be compared between NELCIN-B3 and standard protocol for managing early-detected lung nodules. The effectiveness of quantitative measurement of CT imaging biomarkers for early detection of lung cancer, COPD and CVD will be evaluated.

CONCLUSION

We expect that the quantitative assessment of the CT imaging biomarkers will reduce the number of unnecessary referrals for early detected lung nodules, and will improve the early detection of COPD and CVD in a Chinese urban population.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03988322. Registered on 14 June 2019.

Evaluation of the cardiovascular symptom index for midlife women in multiethnic/racial midlife women

The authors' purpose of this study was to evaluate the validity and reliability of the Cardiovascular Symptom Index for Midlife Women in four ethnic/racial groups of midlife women in the U.S. Data from two internet surveys were used for this secondary analysis. In the construct validity test, five factors were extracted among White and Hispanic women, while more than five factors were extracted among Asian and African American women. In the convergent validity test, all ethnic/racial groups showed similar patterns. Adequate internal consistency among was shown. The Cardiovascular Symptom Index for Midlife Women is useful for assessing cardiovascular symptoms in multiethnic/racial women.

Association of behavioral risk factors with self-reported and symptom or measured chronic diseases among adult population (18-69 years) in India: evidence from SAGE study

BACKGROUND

The objective is to analyze the behavioral risk factors among the adult population and to identify the determinants of and their association with self-reported and symptom or measured chronic diseases in India.

METHODS

The study utilized data from the Study on Global Aging and Adult Health (SAGE), Wave 1 (2007). Logistic regression was applied to examine the association of self-reported and symptom or measured chronic diseases with behavioral risk factors and socioeconomic-demographic covariates.

RESULTS

The results show that the prevalence of the symptom or measured chronic diseases was higher (41.9%) than that of the self-reported chronic diseases (24.1%). The moderate and vigorous physical activity was less likely to be associated with self-reported depression, arthritis, and stroke, but more likely to be associated with the symptom or measured based arthritis and asthma compared to physical inactivity. Adequate intake of fruits and vegetables was significantly less likely to be associated with angina, COPD, and asthma; however, it was more than three times more likely to be associated (OR: 3.45; 95% CI: 1.99-5.97) with self-reported depression. Infrequent moderate alcohol drinking was statistically two times more associated (OR: 1.83; 95% CI: 1.04-3.21) with the symptom or measured based COPD than non-drinking. Likewise, any type of tobacco use was found to be about four times more associated (OR: 3.59; 95% CI: 1.07-12.13) with self-reported stroke. Both self-reported and symptom or measured hypertension, arthritis, and diabetes were associated with overweight, while hypertension was associated with obesity. Females and increased age came out as significant predictors of both self-reported and symptom or measured chronic diseases.

CONCLUSION

The prevalence of chronic diseases and their association with BRFs and socioeconomic and demographic covariates differ markedly when assessed against self-reported criteria versus symptom or measured criteria. Adequate intake of fruits and vegetables is a crucial behavior that controls and delays the onset of chronic diseases. The study suggests that the National Program should remain focused on behavioral risk factors for maximum returns on health outcomes and that proper awareness and knowledge must be spread about healthy lifestyle behaviors throughout the country.

Chronic Noncommunicable Diseases in 6 Low- and Middle-Income Countries: Findings From Wave 1 of the World Health Organization's Study on Global Ageing and Adult Health (SAGE)

In this paper, we examine patterns of self-reported diagnosis of noncommunicable diseases (NCDs) and prevalences of algorithm/measured test-based, undiagnosed, and untreated NCDs in China, Ghana, India, Mexico, Russia, and South Africa. Nationally representative samples of older adults aged ≥50 years were analyzed from wave 1 of the World Health Organization's Study on Global Ageing and Adult Health (2007-2010; n = 34,149). Analyses focused on 6 conditions: angina, arthritis, asthma, chronic lung disease, depression, and hypertension. Outcomes for these NCDs were: 1) self-reported disease, 2) algorithm/measured test-based disease, 3) undiagnosed disease, and 4) untreated disease. Algorithm/measured test-based prevalence of NCDs was much higher than self-reported prevalence in all 6 countries, indicating underestimation of NCD prevalence in low- and middle-income countries. Undiagnosed prevalence of NCDs was highest for hypertension, ranging from 19.7% (95% confidence interval (CI): 18.1, 21.3) in India to 49.6% (95% CI: 46.2, 53.0) in South Africa. The proportion untreated among all diseases was highest for depression, ranging from 69.5% (95% CI: 57.1, 81.9) in South Africa to 93.2% (95% CI: 90.1, 95.7) in India. Higher levels of education and wealth significantly reduced the odds of an undiagnosed condition and untreated morbidity. A high prevalence of undiagnosed NCDs and an even higher proportion of untreated NCDs highlights the inadequacies in diagnosis and management of NCDs in local health-care systems.

Prevalence of coronary artery disease and its risk factors in Kerala, South India: a community-based cross-sectional study

BACKGROUND

There are no recent data on prevalence of coronary artery disease (CAD) in Indians. The last community based study from Kerala, the most advanced Indian state in epidemiological transition, was in 1993 that reported 1.4% definite CAD prevalence. We studied the prevalence of CAD and its risk factors among adults in Kerala.

METHODS

In a community-based cross sectional study, we selected 5167 adults (mean age 51 years, men 40.1%) using a multistage cluster sampling method. Information on socio-demographics, smoking, alcohol use, physical activity, dietary habits and personal history of hypertension, diabetes, and CAD was collected using a structured interview schedule. Anthropometry, blood pressure, electrocardiogram, and biochemical investigations were done using standard protocols. CAD and its risk factors were defined using standard criteria. Comparisons of age adjusted prevalence were done using two tailed proportion tests.

RESULTS

The overall age-adjusted prevalence of definite CAD was 3.5%: men 4.8%, women 2.6% (p < 0.001). Prevalence of any CAD was 12.5%: men 9.8%, women 14.3% (p < 0.001). There was no difference in definite CAD between urban and rural population. Physical inactivity was reported by 17.5 and 18% reported family history of CAD. Other CAD risk factors detected in the study were: overweight or obese 59%, abdominal obesity 57%, hypertension 28%, diabetes 15%, high total cholesterol 52% and low level of high density lipoprotein cholesterol 39%. Current smoking was reported only be men (28%).

CONCLUSION

The prevalence of definite CAD in Kerala increased nearly three times since 1993 without any difference in urban and rural areas. Most risk factors of CAD were highly prevalent in the state. Both population and individual level approaches are warranted to address the high level of CAD risk factors to reduce the increasing prevalence of CAD in this population.

Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report

OBJECTIVES

To review information on cardiovascular health and migration, to stress the attention of researchers that much needs to be done in the collection of sound data in Italy and to allow policy makers identifying this issue as an important public health concern.

BACKGROUND

In Italy, the rate of immigrants in the total number of residents increased from 2.5% in 1990 to 7.4% in 2010, and currently exceeds 10% in regions such as Lombardia, Emilia Romagna and Toscana.

METHODS

A consensus statement was developed by approaching relevant Italian national scientific societies involved in cardiovascular prevention. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. To obtain a widespread consensus, drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft was finally approved by scientific societies.

RESULTS

In several western European countries, the prevalence of hypertension, diabetes, chronic kidney disease, obesity and metabolic syndrome was found to be higher among immigrants than in the native population. Although migrants are often initially healthier than non-migrant populations in their host countries, genetic factors, and changing environments with lifestyle changes, social exclusion and insufficient medical control may expose them to health challenges. Cultural reasons may also hamper both the dissemination of prevention strategies and migrant communication with healthcare providers. However, great diversity exists across and within different groups of migrants, making generalizations very difficult and many countries do not collect registry or survey data for migrant's health.

CONCLUSIONS

In the present economic context, the European Union is placing great attention to improve data collection for migrant health and to support the implementation of specific prevention policies aimed at limiting the future burden of cardiovascular and renal disease, and the consequent load for health systems. Wider initiatives on the topic are awaited in Italy.

Are estimates of socioeconomic inequalities in chronic disease artefactually narrowed by self-reported measures of prevalence in low-income and middle-income countries? Findings from the WHO-SAGE survey

BACKGROUND

The use of self-reported measures of chronic disease may substantially underestimate prevalence in low-income and middle-income country settings, especially in groups with lower socioeconomic status (SES). We sought to determine whether socioeconomic inequalities in the prevalence of non-communicable chronic diseases (NCDs) differ if estimated by using symptom-based or criterion-based measures compared with self-reported physician diagnoses.

METHODS

Using population-representative data sets of the WHO Study of Global Ageing and Adult Health (SAGE), 2007-2010 (n=42 464), we calculated wealth-related and education-related concentration indices of self-reported diagnoses and symptom-based measures of angina, hypertension, asthma/chronic lung disease, visual impairment and depression in three 'low-income and lower middle-income countries'-China, Ghana and India-and three 'upper-middle-income countries'-Mexico, Russia and South Africa.

RESULTS

SES gradients in NCD prevalence tended to be positive for self-reported diagnoses compared with symptom-based/criterion-based measures. In China, Ghana and India, SES gradients were positive for hypertension, angina, visual impairment and depression when using self-reported diagnoses, but were attenuated or became negative when using symptom-based/criterion-based measures. In Mexico, Russia and South Africa, this distinction was not observed consistently. For example, concentration index of self-reported versus symptom-based angina were: in China: 0.07 vs. -0.11, Ghana: 0.04 vs. -0.21, India: 0.02 vs. -0.16, Mexico: 0.19 vs. -0.22, Russia: -0.01 vs. -0.02 and South Africa: 0.37 vs. 0.02.

CONCLUSIONS

Socioeconomic inequalities in NCD prevalence tend to be artefactually positive when using self-report compared with symptom-based or criterion-based diagnostic criteria, with greater bias occurring in low-income countries. Using standardised, symptom-based measures would provide more valid estimates of NCD inequalities.

Chest pain symptom scoring can improve the quality of referrals to Rapid Access Chest Pain Clinic

Typical stable angina is a clinical diagnosis based on history. The challenge for GPs in primary care is to identify those patients who are presenting with either possible or typical angina symptoms and refer onwards for specialist assessment in the local Rapid Access Chest Pain Clinic (RACPC). Our initial information gathering study suggested that referring GPs may be cautiously overdiagnosing angina in primary care, potentially resulting in avoidable or unnecessary referrals to RACPC. We sought a practical and cost effective solution to reducing avoidable referrals by assisting GPs with chest pain discrimination. We tested a change of referral form incorporating chest pain symptom scoring to see whether GP referral quality could be improved and then assessed its impact post implementation. GPs that used the chest pain symptom scoring questionnaire were more than twice as likely to correctly discriminate non-cardiac chest pain. Our post implementation study of the new referral form showed that the proportion of referrals to RACPC with diagnosis of non-cardiac chest pain reduced by almost 19%, and there was a statistically significant 30% fall in the total number of referrals to RACPC. This was likely to be driven by the deterrent effect of the novel referral form on avoidable referrals. Fewer avoidable referrals results in shorter wait times for specialist review, reduces the risk of waiting time breach, and improves RACPC efficiency. In summary, chest pain symptom scoring resulted in improved GP discrimination of chest pain, improved referral quality, fewer overall referrals to RACPC and shorter patient wait times. These benefits were achieved without using additional financial resources and without the time or capital expense of training GPs. These findings could assist GPs and Clinical Commisioning Groups to achieve cost savings by reducing avoidable secondary care referrals.

How good is "very good"? Translation effect in the racial/ethnic variation in self-rated health status

PURPOSE

To examine the influence of translation when measuring and comparing self-rated health (SRH) measured with five response categories (excellent, very good, good, fair, and poor), across racial/ethnic groups.

METHODS

Using data from the California Health Interview Survey, which were administered in five languages, we analyzed variations in the five-category SRH across five racial/ethnic groups: non-Hispanic white, Latino, Chinese, Vietnamese, and Korean. Logistic regression was used to estimate independent effects of race/ethnicity, culture, and translation on SRH, after controlling for risk factors and other measures of health status.

RESULTS

Latinos, Chinese, Vietnamese, and Koreans were less likely than non-Hispanic whites to rate their health as excellent or very good and more likely to rate it as good, fair, or poor. This racial/ethnic difference diminished when adjusting for acculturation. Independently of race/ethnicity, respondents using non-English surveys were less likely to answer excellent (OR = 0.24-0.55) and very good (OR = 0.30-0.34) and were more likely to answer fair (OR = 2.48-4.10) or poor (OR = 2.87-3.51), even after controlling for other measures of SRH.

CONCLUSIONS

Responses to the five-category SRH question depend on interview language. When responding in Spanish, Chinese, Korean, or Vietnamese, respondents are more likely to choose a lower level SRH category, "fair" in particular. If each SRH category measured in different languages is treated as equivalent, racial/ethnic disparities in SRH among Latinos and Asian subgroups, as compared to non-Hispanic whites, may be exaggerated.

Family history: impact on coronary heart disease risk assessment beyond guideline-defined factors

OBJECTIVE

Family history (FH) provides insights into the effects of shared genomic susceptibilities, environments and behaviors, making it a potentially valuable risk assessment tool for chronic diseases. We assessed whether coronary heart disease (CHD) risk assessment is improved when FH information is added to other clinical information recommended in guidelines.

METHODS

We applied logistic regression analyses to cross-sectional data originally obtained from a UK study of women who delivered a live-born infant between 1951 and 1970. We developed 3 models: Model 1 included only the covariates in a guideline applicable to the population, Model 2 added FH to Model 1, and Model 3 included a fuller range of risk factors. For each model, its ability to discriminate between study subjects with and those without CHD was evaluated and its impact on risk classification examined using the net reclassification index.

RESULTS

FH was an independent risk factor for CHD (odds ratio = 1.7, 95% confidence interval = 1.26-2.47) and improved discrimination beyond guideline-defined clinical factors (p < 0.0006). However, the difference in the area under the curve of 2.8% and the extent of patient reclassification resulting from the inclusion of FH were small (p = 0.11).

CONCLUSION

While FH were a significant independent risk factor for CHD, it added little to risk factors typically included in guidelines.

Socioeconomic inequalities in non-communicable diseases prevalence in India: disparities between self-reported diagnoses and standardized measures

BACKGROUND

Whether non-communicable diseases (NCDs) are diseases of poverty or affluence in low-and-middle income countries has been vigorously debated. Most analyses of NCDs have used self-reported data, which is biased by differential access to healthcare services between groups of different socioeconomic status (SES). We sought to compare self-reported diagnoses versus standardised measures of NCD prevalence across SES groups in India.

METHODS

We calculated age-adjusted prevalence rates of common NCDs from the Study on Global Ageing and Adult Health, a nationally representative cross-sectional survey. We compared self-reported diagnoses to standardized measures of disease for five NCDs. We calculated wealth-related and education-related disparities in NCD prevalence by calculating concentration index (C), which ranges from -1 to +1 (concentration of disease among lower and higher SES groups, respectively).

FINDINGS

NCD prevalence was higher (range 5.2 to 19.1%) for standardised measures than self-reported diagnoses (range 3.1 to 9.4%). Several NCDs were particularly concentrated among higher SES groups according to self-reported diagnoses (Csrd) but were concentrated either among lower SES groups or showed no strong socioeconomic gradient using standardized measures (Csm): age-standardised wealth-related C: angina Csrd 0.02 vs. Csm -0.17; asthma and lung diseases Csrd -0.05 vs. Csm -0.04 (age-standardised education-related Csrd 0.04 vs. Csm -0.05); vision problems Csrd 0.07 vs. Csm -0.05; depression Csrd 0.07 vs. Csm -0.13. Indicating similar trends of standardized measures detecting more cases among low SES, concentration of hypertension declined among higher SES (Csrd 0.19 vs. Csm 0.03).

CONCLUSIONS

The socio-economic patterning of NCD prevalence differs markedly when assessed by standardized criteria versus self-reported diagnoses. NCDs in India are not necessarily diseases of affluence but also of poverty, indicating likely under-diagnosis and under-reporting of diseases among the poor. Standardized measures should be used, wherever feasible, to estimate the true prevalence of NCDs.

The risk for coronary heart disease according to insulin resistance with and without type 2 diabetes

OBJECTIVE

To examine the role of insulin resistance versus hyperglycemia in the risk for coronary heart disease (CHD) and to explore the interaction of insulin resistance with hyperglycemia.

METHODS

This is a cross-sectional study based on the National Health and Nutrition Examination Survey III (NHANES). 4,825 subjects were selected from 9,737 adults aged ³40 years excluding those with fasting <8 hours, type 1 diabetes, pregnancy, or missing data. Insulin resistance was calculated using the HOMA II and then log-transformed (log IR). Odds ratios (OR) of CHD was obtained with multiple logistic regression with reference to non-diabetics with log IR > 1.

RESULTS

CHD and type 2 diabetes were present in 9.1 % and 10.5%. Elevated insulin resistance was common; diabetics and non-diabetics with log IR > 1 constituted 6.3% and 12.1% of the population, respectively. ORs for CHD increased as insulin resistance increased in both non-diabetic and diabetics. When log IR > 1, the risk for CHD was not different between diabetics and non-diabetics (OR 1.12, 95% CI; 0.76-1.65). Furthermore, the risk for CHD was higher in non-diabetics with log IR > 1 than in diabetics with log IR1 (OR 0.55, 95% CI; 0.36-0.85).

CONCLUSIONS

Insulin resistance was a greater risk for CHD than type 2 diabetes. Non-diabetics can have a higher risk for CHD than diabetics when insulin resistance is elevated. More research is warranted to develop strategies to identify and treat insulin resistance.

Rose Angina Questionnaire: validation with cardiologists' diagnoses to detect coronary heart disease in Bangladesh

AIM/OBJECTIVES

The study aimed to validate the Rose Angina Questionnaire (RAQ) to detect coronary heart disease (CHD) by comparing with cardiologists' diagnoses in Bangladesh.

METHODS

Patients aged 40-75 years attending to two cardiac hospitals were diagnosed as either CHD positive or CHD negative by cardiologists. The RAQ was used to reclassify them into CHD positive [RAQ] and CHD negative [RAQ].

FINDINGS

There were 302 CHD positive [cardiologists] and 302 CHD negative [cardiologists] individuals. The RAQ reclassified 194 individuals as CHD positive [RAQ] and 409 individuals as CHD negative [RAQ]. Therefore, the RAQ had 53% sensitivity and 89% specificity. There was no difference in sensitivity and specificity during subgroup analyzes by age and gender; the sensitivity was higher among people from lower socio-economic status.

CONCLUSION

The RAQ, having moderate sensitivity but high specificity to detect CHD, can be used to screen individuals at risk of CHD in large-scale epidemiological surveys.

Using the Rose Angina Questionnaire cross-culturally: the importance of consulting lay people when translating epidemiological questionnaires

OBJECTIVES

The Rose Angina Questionnaire (RAQ) is an important measure of coronary heart disease prevalence. It has been shown to perform inconsistently across some ethnic groups in Britain. This study investigates whether the best available versions of the RAQ in Punjabi and Cantonese were linguistically equivalent to the English version.

DESIGN

Interviews were carried out with lay people from the Pakistani, Chinese and European-origin communities in Scotland to assess the versions of the RAQ used in the Newcastle Heart Project (the best available versions). For each questionnaire item, participants were asked to elaborate on their understanding of the question and the meaning of keywords or phrases.

RESULTS

Problems were discovered with the Punjabi and Cantonese translations of the RAQ. For example, the translation for 'chest' was interpreted by some Pakistani and Chinese women to mean 'breasts'. 'Walking uphill' was translated in Chinese as 'walking the hill', without stipulation of the direction, so that some Cantonese speakers interpreted the question as pertaining to walking downhill. Many Chinese interpreted RAQ items to be referring to breathlessness rather than chest pain due to ambiguous wording.

CONCLUSION

Existing versions of the RAQ are unlikely to be yielding data that are cross-culturally valid or comparable. For robust health survey research in languages other than that in which the questionnaire was developed, lay assessment of questionnaires prior to and after translation is a necessity rather than a luxury.

Validation of the Edinburgh Claudication Questionnaire in 1st generation Black African-Caribbean and South Asian UK migrants: a sub-study to the Ethnic-Echocardiographic Heart of England Screening (E-ECHOES) study

Background

We determined the diagnostic accuracy of the Edinburgh Claudication Questionnaire (ECQ) in 1^st generation Black African-Caribbean UK migrants as previous diagnostic questionnaires have been found to be less accurate in this population. We also determined the diagnostic accuracy of translated versions of the ECQ in 1^st generation South Asian UK migrants, as this has not been investigated before.

Methods

Subjects were recruited from the Ethnic-Echocardiographic Heart of England Screening (E-ECHOES) study, a community based screening survey for heart failure in minority ethnic groups. Translated versions of the ECQ were prepared following a recognised protocol. All participants attending screening between October 2007 and February 2009 were asked to complete the ECQ in the language of their choice (English, Punjabi, Bengali, Urdu, Hindi or Gujarati). Subjects answering positively to experiencing leg pain or discomfort on walking were asked to return to have Ankle Brachial Pressure Index (ABPI) measured.

Results

154 out of 2831 subjects participating in E-ECHOES (5.4%) were eligible to participate in this sub-study, for which 74.3% returned for ABPI assessment. Non-responders were younger than participants (59[9] vs. 65[11] years; p = 0.015). Punjabi, English and Bengali questionnaires identified participants with Intermittent Claudication, so these questionnaires were assessed. The sensitivities (SN), specificities (SP), positive (PPV) and negative (NPV) predictive values were calculated. English: SN: 50%; SP: 68%; PPV: 43%; NPV: 74%. Punjabi: SN: 50%; SP: 87%; PPV: 43%; NPV: 90%. Bengali: SN: 33%; SP: 50%; PPV: 13%; NPV: 73%. There were significant differences in diagnostic accuracy between the 3 versions (Punjabi: 83.8%; Bengali: 45%; English: 62.2%; p < 0.0001). No significant differences were found in sensitivity and specificity between illiterate and literate participants in any of the questionnaires and there was no significant different difference between those under and over 60 years of age.

Conclusions

Our findings suggest that the ECQ is not as sensitive or specific a diagnostic tool in 1^st generation Black African-Caribbean and South Asian UK migrants than in the Edinburgh Artery Study, reflecting the findings of other diagnostic questionnaires in these minority ethnic groups. However this study is limited by sample size so conclusions should be interpreted with caution.

Increasing response rates to lifestyle surveys: a pragmatic evidence review

AIMS

Lifestyle surveys are often a key component of a local Joint Strategic Needs Assessment (JSNA), undertaken to inform public health planning. They are usually administered to a large number of people in order to provide a comprehensive profile of population health. However, declining response rates coupled with the under-representation of certain population groups in lifestyle survey data has led to doubts concerning the reliability of findings. In order to inform the design of their own lifestyle survey, NHS Calderdale commissioned an evidence-based review of the methodological literature relating to the administration of lifestyle surveys, with the specific aim of identifying practical and resource-efficient strategies shown to be effective for maximizing whole-population response rates.

METHODS

A pragmatic review of the published literature was undertaken, specifically to explore the most practical and resource-efficient ways to maximize lifestyle survey response rates to the most commonly used methods (postal surveys, face-to-face interviews, telephone interviews and electronic surveys). Electronic databases including MEDLINE, CINAHL, DARE, EMBASE and PsychINFO were searched. Empirical evidence published in the last 10 years was identified and citation tracking performed on all retrieved articles. An internet search for 'grey literature' was also conducted.

RESULTS

The postal questionnaire remains an important lifestyle survey tool, but reported response rates have decreased rapidly in recent years. Interviews and telephone surveys are recommended in order to supplement data from postal questionnaires and increase response rates in some population groups, but costs may be prohibitive. Electronic surveys are a cheaper alternative, but the empirical evidence on effectiveness is inconclusive. Careful planning and tailoring of survey design to the characteristics of target populations can increase response rates and representativeness of lifestyle survey data.

CONCLUSIONS

The results of this pragmatic review could provide a valuable resource for those involved in the design and administration of lifestyle surveys.

Patients' descriptions of angina symptoms: a qualitative study of primary care patients

BACKGROUND

Initial diagnosis of angina in primary care is based on the history of symptoms as described by the patient in consultation with their GP. Deciphering and categorising often complex symptom narratives, therefore, represents an ongoing challenge in the early diagnosis of angina in primary care.

AIM

To explore how patients with a preexisting angina diagnosis describe their symptoms.

METHOD

Semi-structured interviews were conducted with 64 males and females, identified from general practice records as having received a diagnosis of angina within the previous 5 years.

RESULTS

While some patients described their angina symptoms in narratives consistent with typical anginal symptoms, others offered more complex descriptions of their angina experiences, which were less easy to classify. The latter was particularly the case for severe coronary artery disease, where some patients tended to downplay chest pain or attribute their experience to other causes.

CONCLUSION

Patients with a known diagnosis of angina do not always describe their symptoms in a way that is consistent with Diamond and Forrester's diagnostic framework for typicality of angina. Early diagnosis of angina in primary care requires that GPs operate with a broad level of awareness of the various ways in which their patients describe their symptoms.

Incidence and prognosis of angina pectoris in South Asians and Whites: 18 years of follow-up over seven phases in the Whitehall-II prospective cohort study

BACKGROUND

Whether the higher coronary mortality in South Asians compared with White populations is due to a higher incidence of disease is not known. This study assessed cumulative incidence of chest pain in South Asians and Whites, and prognosis of chest pain.

METHODS

Over seven phases of 18-year follow-up of the Whitehall-II study (9,775 civil servants: 9,195 White, 580 South Asian), chest pain was assessed using the Rose questionnaire. Coronary death/non-fatal myocardial infarction was examined comparing those with chest pain to those with no chest pain at baseline.

RESULTS

South Asians had higher cumulative frequencies of typical angina by Phase 7 (17.0 versus 11.3%, P < 0.001) and exertional chest pain (15.4 versus 8.5%, P < 0.001) compared with Whites. Typical angina and exertional chest pain at baseline were associated with a worse prognosis compared with those with no chest pain in both groups (typical angina, South Asians: HR, 4.67 and 95% CI, 2.12-0.30; Whites: HR, 3.56 95% CI, 2.59-4.88). Baseline non-exertional chest pain did not confer a worse prognosis. Across all types of pain, prognosis was worse in South Asians.

CONCLUSION

South Asians had higher cumulative incidence of angina than Whites. In both, typical angina and exertional chest pain were associated with worse prognosis compared with those with no chest pain.

The prevalence of angina symptoms and association with cardiovascular risk factors, among rural, urban and rural to urban migrant populations in Peru

Background

Rural-to-urban migration in low- and middle-income countries causes an increase in individual cardiovascular risk. Cost-effective interventions at early stages of the natural history of coronary disease such as angina may stem an epidemic of premature coronary deaths in these countries. However, there are few data on the prevalence of angina in developing countries, whilst the understanding the aetiology of angina is complicated by the difficulty in measuring it across differing populations.

Methods

The PERU MIGRANT study was designed to investigate differences between rural-to-urban migrant and non-migrant groups in specific cardiovascular disease risk factors. Mass-migration seen in Peru from 1980s onwards was largely driven by politically motivated violence resulting in less 'healthy migrant' selection bias. The Rose angina questionnaire was used to record chest pain, which was classified definite, possible and non-exertional. Mental health was measured using the General Health Questionnaire (GHQ-12). Mantel-Haenszel odds ratios (adjusted for age, sex, cardiovascular disease risk factors and mental health) were used to assess the risk of chest pain in the migrant and urban groups compared to the rural group, and further to assess the relationship (age and sex-adjusted) between risk factors, mental health and chest pain.

Results

Compared to the urban group, rural dwellers had a greatly increased likelihood of possible/definite angina (multi-adjusted OR 2.82 (1.68- 4.73)). Urban and migrant groups had higher levels of risk factors (e.g. smoking - 20.1% urban, 5.5% rural). No diabetes was seen in the rural dwellers who complained of possible/definite angina. Rural dwellers had a higher prevalence of mood disorder and the presence of a mood disorder was associated with possible/definite angina in all three groups, but not consistently with non-exertional chest pain.

Conclusion

Rural groups had a higher prevalence of angina as measured by Rose questionnaire than migrants and urban dwellers, and a higher prevalence of mood disorder. The presence of a mood disorder was associated with angina. The Rose angina questionnaire may not be of relevance to rural populations in developing countries with a low pre-test probability of coronary disease and poor mental health.

Relation between common allergic symptoms and coronary heart disease among NHANES III participants

We investigated whether there is an increased risk of coronary heart diseases (CHD) in those with common allergic symptoms using the NHANES III, which is a representative sample of the United States population in 1988 to 1994. CHD was defined by Rose questionnaire and history of heart attack. Allergic symptoms were categorized into no symptoms (NO), rhinoconjunctivitis without wheezing (RC), and wheezing (WZ) based on symptoms. Multivariate logistic regression was used to obtain odds ratios (ORs) of CHD. Eight thousand six hundred fifty-three nonpregnant subjects ≥20 years old with overnight fasting ≥8 hours were included. CHD was present in 5.9% of the population; 36.5% did not have allergic symptoms (NO), 45.9% had RC, and 17.6% had WZ. The prevalence of CHD was 3.9% in NO, 4.8% in RC, and 12.8% in WZ (p <0.001). Compared to NO, unadjusted ORs of CHD were 1.24 (95% confidence interval 0.94 to 1.62) in RC and 3.58 (2.68 to 4.78) in WZ and ORs adjusted for sociodemographic factors and co-morbidities were 1.40 (1.02 to 1.92) in RC and 2.64 (1.79 to 3.90) in WZ. Only the group of women <50 years of age had significantly increased ORs in RC and WZ. In conclusion, common allergic symptoms were significantly associated with an increased risk of CHD.

The Iranian version of Angina Pectoris characteristics questionnaire: reliability assessment

AIMS

To evaluate internal consistency and test-retest reliability of the Iranian version of the Angina Pectoris characteristics questionnaire.

BACKGROUND

To evaluate symptoms in patients with Angina Pectoris, the Iranian version of the Angina Pectoris characteristics questionnaire was created by combining items from Modified Rose Questionnaire, Short Form-McGill Questionnaire and the Accompanying Symptom Checklist. The Angina Pectoris characteristics questionnaire has been developed and validated recently although it required assessment of its reliability.

DESIGN

Reliability study using test and retest.

METHOD

One hundred and ten coronary heart disease patients with Angina Pectoris were included. The test-retest reliability of the instrument was estimated for measurement after 15 days.

RESULT

The analysis of the result indicated that internal consistency was found adequate at both assessments (Cronbach's alpha = 0.65) for test and retest. There was no significant difference between test and retest. The intra-class correlation coefficient ranged from 0.76-0.98.

CONCLUSION

The Angina Pectoris characteristics questionnaire is a reliable instrument for the assessment of Angina Pectoris characteristics in a Persian population.

RELEVANCE TO CLINICAL PRACTICE

The Angina Pectoris characteristics questionnaire can be used with confidence in Iranian coronary heart disease patients for Assessing Angina Pectoris symptom.

Obesity-related non-communicable diseases: South Asians vs White Caucasians

South Asians are at higher risk than White Caucasians for the development of obesity and obesity-related non-communicable diseases (OR-NCDs), including insulin resistance, the metabolic syndrome, type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). Rapid nutrition and lifestyle transitions have contributed to acceleration of OR-NCDs in South Asians. Differences in determinants and associated factors for OR-NCDs between South Asians and White Caucasians include body phenotype (high body fat, high truncal, subcutaneous and intra-abdominal fat, and low muscle mass), biochemical parameters (hyperinsulinemia, hyperglycemia, dyslipidemia, hyperleptinemia, low levels of adiponectin and high levels of C-reactive protein), procoagulant state and endothelial dysfunction. Higher prevalence, earlier onset and increased complications of T2DM and CHD are often seen at lower levels of body mass index (BMI) and waist circumference (WC) in South Asians than White Caucasians. In view of these data, lower cut-offs for obesity and abdominal obesity have been advocated for Asian Indians (BMI; overweight >23 to 24.9 kg m(-2) and obesity ≥ 25 kg m(-2); and WC; men ≥ 90 cm and women ≥ 80 cm, respectively). Imbalanced nutrition, physical inactivity, perinatal adverse events and genetic differences are also important contributory factors. Other differences between South Asians and White Caucasians include lower disease awareness and health-seeking behavior, delayed diagnosis due to atypical presentation and language barriers, and religious and sociocultural factors. All these factors result in poorer prevention, less aggressive therapy, poorer response to medical and surgical interventions, and higher morbidity and mortality in the former. Finally, differences in response to pharmacological agents may exist between South Asians and White Caucasians, although these have been inadequately studied. In view of these data, prevention and management strategies should be more aggressive for South Asians for more positive health outcomes. Finally, lower cut-offs of obesity and abdominal obesity for South Asians are expected to help physicians in better and more effective prevention of OR-NCDs.

Angina in primary care in Goa, India: sex differences and associated risk factors

BACKGROUND

Little is known about the prevalence of angina in people seen in Indian general practices. The authors assessed the prevalence of angina and its associated risk factors in Goan general practices.

METHODS

Cross-sectional study on consecutive attendees in nine private general practices in Goa, India. All participants completed the Rose Angina Questionnaire, to ascertain the presence of angina. Other demographic, clinical and biochemical data were also collected.

RESULTS

1556 (626 men and 930 women) consecutive attendees aged 30 to 75 years. Angina was detected in 37 (5.9%, 95% CI 2.4 to 9.4%) men and 99 (10.6%, 95% CI=7.4 to 11.2%) women. The prevalence of angina increased with age in both sexes but was greater in women between aged 46-60 (OR=4.3 (95% CI 2.0 to 9.2)) when compared with men. When compared with men, the odds of angina in women of all ages was 2.03 (95% CI 1.10 to 3.75) after controlling for confounders. Angina was associated with depressive and/or anxiety symptoms in both sexes (men OR=5.65, 95% CI=2.25 to 14.16; women OR=2.18, 95% CI=1.01 to 4.69) and with hypertension in men (OR=3.82, 95% CI=1.57 to 9.30) and family history of coronary heart disease (OR=1.53, 95% CI 1.05 to 2.24) in women. Borderline/high total cholesterol levels (OR=0.5, 95% CI 0.28 to 0.89) in women were associated with a reduced risk of angina.

CONCLUSION

Women attending general practices in Goa, India are at greater risk of angina than men. Depression/anxiety is strongly associated with angina. Greater awareness of the general practitioners to the disparity in angina between the sexes and its association with psychological distress is required.

Inter-rater and intra-rater reliability of the Bahasa Melayu version of Rose Angina Questionnaire

The objective of the study is to translate the Rose Questionnaire (RQ) into a Bahasa Melayu version and adapt it cross-culturally, and to measure its inter-rater and intrarater reliability. This cross sectional study was conducted in the respondents' homes or workplaces in Kelantan, Malaysia. One hundred respondents aged 30 and above with different socio-demographic status were interviewed for face validity. For each inter-rater and intra-rater reliability, a sample of 150 respondents was interviewed. Inter-rater and intra-rater reliabilities were assessed by Cohen's kappa. The overall inter-rater agreements by the five pair of interviewers at point one and two were 0.86, and intrarater reliability by the five interviewers on the seven-item questionnaire at poinone and two was 0.88, as measured by kappa coefficient. The translated Malay version of RQ demonstrated an almost perfect inter-rater and intra-rater reliability and further validation such as sensitivity and specificity analysis of this translated questionnaire is highly recommended.

Prevalence of Angina in Women Versus Men

Background— In the absence of previous international comparisons, we sought to systematically evaluate, across time and participant age, the sex ratio in angina prevalence in countries that differ widely in the rate of mortality due to myocardial infarction.

Methods and Results— We searched MEDLINE and EMBASE until February 2006 for healthy population studies published in any language that reported the prevalence of angina (Rose questionnaire) in women and men. We obtained myocardial infarction mortality rates from the World Health Organization. A total of 74 reports of 13 331 angina cases in women and 11 511 cases in men from 31 countries were included. Angina prevalence varied widely across populations, from 0.73% to 14.4% (population weighted mean 6.7%) in women and from 0.76% to 15.1% (population weighted mean 5.7%) in men, and was strongly correlated within populations between the sexes ( r =0.80, P <0.0001). Angina prevalence showed a small female excess with a pooled random-effects sex ratio of 1.20 (95% CI 1.14 to 1.28, P <0.0001). This female excess was found across countries with widely differing myocardial infarction mortality rates in women (interquartile range 12.7 to 126.5 per 100 000), was particularly high in the American studies (1.40, 95% CI 1.28 to 1.52), and was higher among nonwhite ethnic groups than among whites. This sex ratio did not differ significantly by participant’s age, the year the survey began, or the sex ratio for mortality due to myocardial infarction.

Conclusions— Over time and at different ages, independent of diagnostic and treatment practices, women have a similar or slightly higher prevalence of angina than men across countries with widely differing myocardial infarction mortality rates.

Performing stable angina pectoris: an ethnographic study

Symptoms play a crucial part in the formulation of medical diagnoses, yet the construction and interpretation of symptom narratives is not well understood. The diagnosis of angina is largely based on symptoms, but a substantial minority of patients diagnosed with "non-cardiac" chest pain go on to have a heart attack. In this ethnographic study our aims were to understand: (1) how the patients' accounts are performed or enacted in consultations with doctors; (2) the ways in which ambiguity in the symptom narrative is managed by doctors; and (3) how doctors reach or do not reach a diagnostic decision. We observed 59 consultations of patients in a UK teaching hospital with new onset chest pain who had been referred for a specialist opinion in ambulatory care. We found that patients rarely gave a history that, without further interrogation, satisfied the doctors, who actively restructured the complex narrative until it fitted a diagnostic canon, detaching it from the patient's interpretation and explanation. A minority of doctors asked about chest pain symptoms outside the canon. Re-structuring into the canonical classification was sometimes resisted by patients who contested key concepts, like exertion. Symptom narratives were sometimes unstable, with central features changing on interrogation and re-telling. When translation was required for South Asian patients, doctors considered the history less relevant to the diagnosis. Diagnosis and effective treatment could be enhanced by research on the diagnostic and prognostic value of the terms patients use to describe their symptoms.

Migration and coronary heart disease: A study of Finnish twins living in Sweden and their co-twins residing in Finland

BACKGROUND

Finland and Sweden are neighbouring countries with a substantially higher incidence and mortality from coronary heart disease (CHD) in Finland. Migration from Finland to Sweden has resulted in a population of about 187,000 Finnish immigrants, with a higher risk of CHD than Swedes. The aim of the present study was to analyse the prevalence of CHD in migrants to Sweden compared with co-twins remaining in Finland.

METHODS

The study population consisted of twin pairs of the Finnish Twin Cohort Study where at least one twin had lived one year or more in Sweden, including 1,534 subjects and 251 complete twin pairs discordant regarding residency in Sweden. Emigrant twins were compared with nonmigrant co-twins regarding prevalence of CHD in 1998. CHD prevalence was assessed by self-reported questionnaires validated using information from a clinical examination.

RESULTS

Self-reported CHD showed a good correspondence with clinical diagnosis. Differences in social and behavioural risk factors for CHD among men were small but emigrants were more physically active than non-migrants. Female emigrants had less overweight and better education, but were more often working class than non-migrants. Intra-pair comparisons restricted to migration discordant pairs showed a tendency towards a reduced prevalence of CHD in the migrant co-twins (0.6; 0.3-1.4). In analyses of all subjects disregarding pair status, emigrants showed a reduced prevalence of CHD compared with subjects always living in Finland (0.6; 0.4-0.9).

CONCLUSION

Emigration from Finland to Sweden may be associated with a reduced prevalence of CHD. The causes are most likely multifactorial and may involve changes in dietary habits, physical activity, psychosocial factors, and inflammation.

Prognosis of stable angina pectoris: why we need larger population studies with higher endpoint resolution

The prognosis of angina was described as "unhappy" by the Framingham investigators and as little different from that of 1-year survivors of acute myocardial infarction. Yet recent clinical trials now report that angina has a good prognosis with adverse outcomes reduced to "normal levels". These disparate prognostic assessments may not be incompatible, applying as they do to population cohorts (Framingham) and selected participants in clinical trials. Comparisons between studies are further complicated by the absence of agreed case definitions for stable angina (contrast this with acute coronary syndromes). Our recent data show that for patients with recent onset symptoms attending chest pain clinics, angina remains a high-risk diagnosis and although many patients receive symptomatic benefit from revascularisation, prognosis is usually unaffected. This leaves little room for complacency and, with angina the commonest initial manifestation of coronary artery disease, there is the opportunity for early detection, risk stratification and treatment to modify outcomes. Meanwhile, larger population-based studies are needed to define the patient journey from earliest presentation through the various syndrome transitions to coronary or noncardiac death in order to increase understanding of the aetiological and prognostic differences between the different coronary disease phenotypes.

Epidemiology of angina pectoris: role of natural language processing of the medical record

BACKGROUND

The diagnosis of angina is challenging because it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding.

OBJECTIVE

To test the hypothesis that NLP of the EMR improves angina pectoris ascertainment over diagnostic codes.

METHODS

Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina.

RESULTS

Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P < .001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .10). Both approaches had 88% (95% CI 65-100) true-positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over a 28-month follow-up.

CONCLUSION

EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

Ethnicity and cardiovascular disease prevention in the United Kingdom: a practical approach to management

The United Kingdom is a diverse society with 7.9% of the population from black and minority ethnic groups (BMEGs). The causes of the excess cardiovascular disease (CVD) and stroke morbidity and mortality in BMEGs are incompletely understood though socio-economic factors are important. However, the role of classical cardiovascular (CV) risk factors is clearly important despite the patterns of these risk factors varying significantly by ethnic group. Despite the major burden of CVD and stroke among BMEGs in the UK, the majority of the evidence on the management of such conditions has been based on predominantly white European populations. Moreover, the CV epidemiology of African Americans does not represent well the morbidity and mortality experience seen in black Africans and black Caribbeans, both in Britain and in their native African countries. In particular, atherosclerotic disease and coronary heart disease are still relatively rare in the latter groups. This is unlike the South Asian diaspora, who have prevalence rates of CVD in epidemic proportions both in the diaspora and on the subcontinent. As the BMEGs have been under-represented in research, a multitude of guidelines exists for the 'general population.' However, specific reference and recommendation on primary and secondary prevention guidelines in relation to ethnic groups is extremely limited. This document provides an overview of ethnicity and CVD in the United Kingdom, with management recommendations based on a roundtable discussion of a multidisciplinary ethnicity and CVD consensus group, all of whom have an academic interest and clinical practice in a multiethnic community.

Acute coronary syndromes and their presentation in Asian and Caucasian patients in Britain

OBJECTIVE

To describe and compare demographics and symptom presentation in Asian and Caucasian patients with acute coronary syndromes.

DESIGN

Long-term prospective survey of symptom presentations in two racial groups.

SETTING

A London hospital.

PARTICIPANTS

A consecutive series of patients admitted to hospital with acute coronary syndromes between November 2001 and November 2005.

MAIN OUTCOME MEASURE

Comparison of demographics and location, character, intensity and symptom distribution at presentation between Asian and Caucasian patients.

RESULTS

Asian patients were younger than Caucasian patients (61 v 69 years, p<0.001) and more had diabetes (43% v 17%, p<0.001). Proportionally, more Asian patients had angina (51% v 37%, p<0.001), but more Caucasian patients had myocardial infarction (63% v 49%, p<0.001) and non-ST elevation infarcts (40% v 29%, p<0.001). Men reported smaller areas of discomfort than women. Asian patients more frequently reported discomfort over the rear of their upper bodies compared to Caucasian patients (46% v 25%, p<0.001) and radiation of discomfort to their arms and necks. A higher percentage of Asian than Caucasian patients demonstrated a "classical" location of symptoms (90% v 82%, p<0.001). Patients with diabetes were more likely to feel no discomfort. A higher percentage of Caucasian than Asian patients presented with "silent" events (13% v 6%, p>0.001), with age being a major determinant.

CONCLUSION

Asian patients were younger, more likely to be diabetic and tended to report a higher intensity of pain and over a greater area of their body, and more frequent discomfort over the rear of their upper thorax than Caucasian patients.

Value of diagnostic tools for myocardial ischemia used in routine clinical practice to predict cardiac events in patients with type 2 diabetes mellitus: a prospective study

OBJECTIVE

To analyze tests used in routine clinical practice for the diagnosis of myocardial ischemia to predict the development of cardiac events in type 2 diabetic patients.

METHODS

The occurrence of cardiac events (new myocardial infarct, myocardial re-vascularization procedures, congestive heart failure, acute pulmonary edema, sudden death, and death after myocardial infarction or pulmonary edema) were prospectively assessed in a cohort of 135 type 2 diabetic patients after up to seven years of follow-up. At baseline, coronary artery disease was assessed by the WHO cardiovascular questionnaire, resting electrocardiogram, and stress myocardial scintigraphy.

RESULTS

Forty-eight cardiac events were observed in 41 patients (10.5 events/100 patients-year). In a Cox's proportional-hazard model only the presence of symptoms of coronary artery disease on the WHO cardiovascular questionnaire alone (RR = 2.13, 95% CI 1.11-4.07, P= 0.022) or in combination with abnormalities on resting ECG (RR= 2.03, 95% CI 1.05-3.92, P= 0.034) or on myocardial scintigraphy (RR= 1.89, 95% CI 1.001-3.57, P= 0.050) predicted cardiac events, adjusted for fasting plasma glucose, mean blood pressure, body mass index, peripheral vascular disease and diabetic nephropathy.

CONCLUSION

The WHO cardiovascular questionnaire, a simple tool for the diagnosis of coronary artery disease, is a significant predictor of cardiac events in type 2 diabetic patients.

Integrated population-based surveillance of noncommunicable diseases: the Pakistan model

The escalating burden of noncommunicable diseases (NCDs) worldwide warrants an urgent public health response. Resource constraints and other factors necessitate an integrated and concerted approach to the range of NCDs. A necessary prerequisite for effective planning, implementation, and evaluation of NCD prevention programs is access to reliable and timely information on mortality, morbidity, risk factors, and their socioeconomic determinants. However, there is limited experience in the setting up of integrated NCD surveillance models in low-resource settings. As part of the National Action Plan for the Prevention and Control of NCDs in Pakistan, an integrated, systematic, and sustainable population-based NCD surveillance system is being established, and will be maintained and expanded over time. This is a common population surveillance mechanism for all NCDs (with the exception of cancer). The model includes population surveillance of main risk factors that predict many NCDs and combines modules on population surveillance of injuries, mental health, and stroke. In addition, the model has been adapted for program evaluation; this will enable it to track implementation processes using appropriate indicators, facilitating an assessment of how interventions work and which components contribute most to success. This paper outlines the first activity in this sequential process, including its merits and limitations.

Is coronary heart disease rising in India? A systematic review based on ECG defined coronary heart disease

The aim of this study was to investigate whether coronary heart disease (CHD) is rising in India and assess the quality of the evidence. Thirty one studies were reviewed. The sample sizes of the studies varied from approximately 500 to 14,000, with response rates generally over 90%. Many did not fulfil basic requirements for epidemiological research and most studies were in or around Delhi. The three incidence studies used different diagnostic criteria; however, the incidence of myocardial infarction (MI) in urban India in the 14 years to 1991 remained similar at about 6/1000 in males and 2/1000 in females. Prevalence range was higher in urban than rural areas in men (35-90/1000 v 17-45/1000) and women (28-93/1000 v 13-43/1000). There was no clear rise in age specific rates in men over a 27 year period, whereas a rise was seen in women. In conclusion, using a relatively objective measure of CHD it was found that CHD is more common in urban than rural areas of India, but there was little evidence of a rise in CHD over time, especially in men.

Population based study of noncardiac chest pain in southern Chinese: Prevalence, psychosocial factors and health care utilization

AIM: Population-based assessment of noncardiac chest pain (NCCP) is lacking. The aim of this study was to evaluate the prevalence, psychosocial factors and health seeking behaviour of NCCP in southern Chinese.

METHODS: A total of 2209 ethnic Hong Kong Chinese households were recruited to participate in a telephone survey to study the epidemiology of NCCP using the Rose angina questionnaire, a validated gastroesophageal reflux disease (GERD) questionnaire and the hospital anxiety-depression scale. NCCP was defined as non-exertional chest pain according to the Rose angina questionnaire and had not been diagnosed as ischaemic heart diseases by a physician.

RESULTS: Chest pain over the past year was present in 454 subjects (20.6%, 95%CI 19-22), while NCCP was present in 307 subjects (13.9%, 95%CI 13-15). GERD was present in 51% of subjects with NCCP and 34% had consulted a physician for chest pain. Subjects with NCCP had a significantly higher anxiety (P < 0.001) and depression score (P = 0.007), and required more days off (P = 0.021) than subjects with no chest pain. By multiple logistic regression analysis, female gender (OR 1.9, 95%CI 1.1-3.2), presence of GERD (OR 2.8, 95%CI 1.6-4.8), and social life being affected by NCCP (OR 6.9, 95%CI 3.3-15.9) were independent factors associated with health seeking behaviour in southern Chinese with NCCP.

CONCLUSION: NCCP is a common problem in southern Chinese and associated with anxiety and depression. Female gender, GERD and social life affected by chest pain were associated with health care utilization in subjects with NCCP.