European Heart Journal Advance Access originally published online on March 18, 2005
European Heart Journal 2005 26(10):996-1010; doi:10.1093/eurheartj/ehi171
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The clinical characteristics and investigations planned in patients with stable angina presenting to cardiologists in Europe: from the Euro Heart Survey of Stable Angina
1Royal Brompton and Harefield NHS Trust, Sydney Street, London SW3 6NP, UK
2London School of Hygiene and Tropical Medicine, London, UK
3Hospital Universitario Gregorio Maranon, Madrid, Spain
4Policlinico S Matteo, Pavia, Italy
5Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
6Hopital Europeen Georges Pompidou, Paris, France
7Hopital Cardiovasculaire et Pneumologique Louis Pradel, Lyons, France
8Herzzentrum Luwigshafen, Ludwigshafen, Germany
9University of Newcastle upon Tyne, Newcastle upon Tyne, UK
10Adelaide and Meath incorporating National Children's Hospital, Dublin, Ireland
11Institute of Cardiology, Warsaw, Poland
12Aarhus University Hospital, Aarhus, Denmark
13University Medical Centre St Radboud, Nijmegen, The Netherlands
Received 15 September 2004; revised 7 January 2005; accepted 13 January 2005; online publish-ahead-of-print 18 March 2005.
* Corresponding author. Tel: +44 207 3518289; fax: +44 207 3518643. E-mail address: c.daly{at}rbh.nthames.nhs.uk or carolinenidhal{at}hotmail.com
See page 949 for the editorial comment on this article (doi:10.1093/eurheartj/ehi294)
Aims The Euro Heart Survey of Stable Angina set out to prospectively study the presentation and management of patients with stable angina as first seen by a cardiologist in Europe, with particular reference to adherence to existing guidelines and regional variability in patient presentation and initial assessment.
Methods and results Consecutive outpatients with a clinical diagnosis by a cardiologist of stable angina were enrolled in the study and 3779 patients were included in the analysis. The average age was 61 years and 58% were male. The majority of patients (88%) had mild to moderate angina, CCS class I or II. Despite a high prevalence of recognized risk factors, 27% did not have cholesterol and 33% did not have glucose measured within 4 weeks of assessment. The resting ECG was abnormal in 41% of patients. An exercise ECG was performed or planned as part of initial investigation in 76% of patients and 18% had a stress imaging test such as perfusion scanning or stress echo. A coronary angiogram was performed or planned in 41%, and 64% had an echo. The time from assessment to investigation varied widely, particularly for angiography. One in 10 patients had neither any form of stress test nor angiography, with marked regional variation. Availability of invasive facilities increased the likelihood of both non-invasive and invasive investigations. Those with more severe symptoms or longer duration of symptoms or a positive non-invasive test were more likely to have angiography. In multivariable analysis, a positive stress test was the strongest predictor of the use of angiography, associated with a six-fold increase in the likelihood of invasive investigation. However, gender and availability of facilities were also predictive.
Conclusion Considerable variation in features at presentation and use of investigations has been identified in the stable angina population in Europe. The evaluation of biochemical cardiovascular risk factors was suboptimal. Overall rates of non-invasive investigation for angina and the clinical appropriateness of factors predictive of the use of invasive investigation were broadly in line with guidelines. However, the influence of access to facilities, and marked international variation in rates and timing of investigation suggest that factors unrelated to clinical need are also influential in the management of patients with stable angina.
Key Words: Stable angina • Presentation • Cardiovascular risk factors • Non-invasive investigation • Stress testing • Coronary angiography
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