Assessing chest pain helps understand risk for obstructive coronary artery disease

An analysis of patients without a history of coronary artery disease who were referred for elective coronary angiography found that those with typical angina and a negative stress test result were most likely to have obstructive coronary artery disease.

Lead researcher John P. Vavalle, MD, MHS, of the University of North Carolina at Chapel Hill School of Medicine, and colleagues published their results online in JAMA Cardiology on March 16.

Gilead Sciences supported the study with an unrestricted educational grant.

“The modern medical era is defined by contemporary diagnostic studies and noninvasive testing,” the researchers wrote. “However, our data demonstrate the critical importance of the art of clinical medicine in understanding the type of [chest pain] and analyzing symptom characteristics to accurately stratify patient risk.”

The researchers identified 15,888 patients in the Duke Databank for Cardiovascular Disease without a history of coronary artery disease who were referred to the cardiac catheterization laboratory between Jan. 1, 1996, and Dec. 31, 2010.

The mean age of patients was 59.5 years old, while 44.2 percent were female and nearly 75 percent were white. Of the patients, 38.8 percent had atypical angina, 36.9 percent had typical angina and 24.3 percent did not have angina.

Of the 4,994 patients who had a stress test before cardiac catheterization, 76.3 percent had no ischemia and the remaining 23.7 percent had ischemia.

Further, 48 percent had obstructive coronary artery disease, 32.6 percent had nonobstructive coronary artery disease and 19.4 percent had no coronary artery disease.

The researchers mentioned that patients with atypical angina were younger and were more likely to be female and white. They added that patients with typical angina had the highest rates of single-vessel (33.6 percent), double-vessel (17.5 percent) and triple-vessel (18.8 percent) disease.

In addition, patients with no ischemic chest pain were most likely to have no obstructive coronary artery disease, while patients with typical angina had the highest rate of obstructive coronary artery disease and the highest rate of MI. The rates of MI did not differ significantly based on pre-cardiac catheterization stress test results.

Revascularization was found in 64 percent of patients with typical angina, 30 percent of patients with atypical angina, 26.9 percent of patients with no chest pain, 35.2 percent of patients with positive stress test results, 47.9 percent of patients with negative stress test results and 40.3 percent of patients with no stress test.

The researchers cited a few limitations of the study, including that it was a single-center observational study and that the causes of death were not known.

“Our study is one of the largest to date to examine the associations between angina type, pre–cardiac catheterization stress test results, and coronary angiography findings,” they wrote. “We believe that this study highlights the importance of clinical judgment and a detailed understanding of patients’ clinical symptoms in identifying those at highest risk for obstructive [coronary artery disease].”