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Prospective Cohort Study Diagnosis: 11 Year Follow up in the Whitehall II Downloaded from bmj.com on 25 April 2006 Prognosis of angina with and without a diagnosis: 11 year follow up in the Whitehall II prospective cohort study Harry Hemingway, Martin Shipley, Annie Britton, Michael Page, Peter Macfarlane and Michael Marmot BMJ 2003;327;895- doi:10.1136/bmj.327.7420.895 Updated information and services can be found at: http://bmj.com/cgi/content/full/327/7420/895 These include: Data supplement "Additional tables figures and questionnaire" http://bmj.com/cgi/content/full/327/7420/895/DC1 References This article cites 17 articles, 13 of which can be accessed free at: http://bmj.com/cgi/content/full/327/7420/895#BIBL 7 online articles that cite this article can be accessed at: http://bmj.com/cgi/content/full/327/7420/895#otherarticles Rapid responses 3 rapid responses have been posted to this article, which you can access for free at: http://bmj.com/cgi/content/full/327/7420/895#responses You can respond to this article at: http://bmj.com/cgi/eletter-submit/327/7420/895 Email alerting Receive free email alerts when new articles cite this article - sign up in the service box at the top right corner of the article Topic collections Articles on similar topics can be found in the following collections Ischaemic heart disease (1924 articles) Notes To order reprints of this article go to: http://www.bmjjournals.com/cgi/reprintform To subscribe to BMJ go to: http://bmj.bmjjournals.com/subscriptions/subscribe.shtml Downloaded from bmj.com on 25 April 2006 Papers Prognosis of angina with and without a diagnosis: 11 year follow up in the Whitehall II prospective cohort study Harry Hemingway, Martin Shipley, Annie Britton, Michael Page, Peter Macfarlane, Michael Marmot Abstract prospective cohort. Population based studies show that International the combination of angina identified by questionnaire Centre for Health Objective To investigate the prognosis of angina and Society, and an abnormality on a resting electrocardiogram Department of among people with and without diagnosis by a doctor identifies groups with increased risk of death.89 Epidemiology and Public Health, and an abnormal cardiovascular test result. Whether this risk is confined to patients who have Design Prospective cohort study with a median follow University College sought medical care and have a diagnosis from a doc- London Medical up of 11 years. tor (visible clinical iceberg) or if it extends to those School, London Setting 20 civil service departments originally located WC1E 6BT without a diagnosis by a doctor (submerged clinical Harry Hemingway in London. 10 iceberg) is not known. The impact of undiagnosed reader in clinical Participants 10 308 civil servants aged 35-55 years at angina on recurrent reports of angina and physical epidemiology baseline. functioning is unclear. Martin Shipley Main outcome measures Recurrent reports of senior lecturer in Our objective therefore was to investigate the prog- medical statistics angina; quality of life (SF-36 physical functioning); nosis of angina among people with and without a Annie Britton non-fatal myocardial infarction; death from any cause diagnosis by a doctor and an abnormal cardiovascular lecturer in epidemiology (n = 344). test result. We defined prognosis by four outcomes: Results 1158 (11.4%) participants developed angina, Michael Page death, myocardial infarction, recurrent reports of research nurse and 813 (70%) had no evidence of diagnosis by a angina, and functional status. Michael Marmot doctor at the time of the initial report. Participants professor of without a diagnosis had an increased risk of impaired epidemiology and physical functioning (age and sex adjusted odds ratio Method public health of 2.36 (95% confidence interval 1.91 to 2.90)) University of Participants Glasgow, compared with those who had neither angina nor We invited all non-industrial civil servants aged 35-55 Department of myocardial infarction throughout follow up. Among years working in the London offices of 20 departments Medical Cardiology, reported cases of angina without a diagnosis, the Royal Infirmary, to participate in this study. The final cohort consisted Glasgow G31 2ER 15.5% with an abnormality on a study of 10 308 participants (3413 women) with an overall Peter Macfarlane electrocardiogram had an increased risk of death response rate of 73%.11 We obtained written informed professor of electrocardiology (hazard ratio 2.37 (1.16 to 4.87)). These effects were consent from participants to examine clinical records. similar in magnitude to those in participants with a Participants completed questionnaires at five phases of Correspondence to: diagnosis of angina. H Hemingway data collection between 1985 and 1999 (fig A on h.hemingway@ Conclusion Undiagnosed angina was common and bmj.com). At phase 5, 7830 participants completed a public-health.ucl.ac.uk had an adverse impact on prognosis comparable to questionnaire (76% response rate from phase 1). At that of diagnosed angina, particularly among people each phase we used the seven item Rose angina ques- bmj.com 2003;327:895 with electrocardiographic abnormalities. Efforts to tionnaire to define angina independent of contact with improve prognosis among people with angina should medical care.12 take account of this submerged clinical iceberg. Diagnosis of angina by a doctor We obtained evidence of a diagnosis of angina from Introduction questionnaire items on diagnosis (four items), investi- During a period of declining incidence of myocardial gation (two items), and treatment (two items) (see infarction, the prevalence of angina remains high, and bmj.com). We examined general practitioner and consultations for angina in primary care have hospital records for details of diagnoses and abnormal increased.1 Government and professional bodies test results among participants reporting positively on increasingly emphasise the importance of systematic any of these eight questionnaire items. We also sought identification and investigation of people with new clinical records where the civil service gave a reason for onset angina on the basis of an assessment of sickness absence as angina or myocardial infarction or prognosis.2–4 when the spell of absence exceeded 21 days. Additional tables, However, people with angina do not necessarily Abnormal test results figures, and 5–7 seek medical care. The size and prognosis of this Regardless of contact with medical care, we investi- questionnaire items group has not been assessed in a contemporary gated each participant with a resting 12 lead appear on bmj.com BMJ VOLUME 327 18 OCTOBER 2003 bmj.com page 1 of 5 Downloaded from bmj.com on 25 April 2006 Papers electrocardiogram at phases 1, 3, and 5. We defined Statistical analysis abnormal results as Q waves (Minnesota codes 1-1 to We compared participants with four categories of 1-3), ST depression (4-1 to 4-4), inverted T waves (5-1 angina, defined by the presence or absence of a to 5-3), or left bundle branch block (7-1).13 Additionally, diagnosis by a doctor or an abnormal test result, with among participants who had sought medical care, we participants who did not have angina or a myocardial defined abnormal test results as the presence of one or infarction throughout follow up. All analyses concern more diseased vessels at coronary angiography or ≥ 1 incident angina among people without previous myo- mm ST depression on exercise electrocardiogram or a cardial infarction. We excluded from all analyses 102 reversible defect on stress imaging. participants with angina or myocardial infarction (n = 224 reports) before phase 1 and 15 participants Outcomes: classification of angina and recurrent not flagged at the Central Registry. By 31 December reports 1999, 344 deaths had occurred among the remaining We classified angina according to evidence of diagnosis 10 191 participants (2.9 per 1000 person years). To by a doctor and the presence of an abnormal test result examine the prognosis of participants after their first (table 1). We made chronological listings of each item of report of angina, we calculated the risk (probability) of epidemiological and clinical record data. We coded pair- specified events occurring in the next five years from wise combinations of evidence from two columns in the their rate of occurrence. We calculated person years of table in a hierarchy starting from a clinical record of survival by using the date of phase 1 and the dates of diagnosis of angina plus an abnormal coronary angina events and death or censoring at the end of angiogram at the top (first row) down to angina 1999. We described the relation between types of identified by the Rose angina questionnaire (“Rose angina and subsequent mortality with hazard ratios angina”) plus a normal study electrocardiogram at the and 95% confidence intervals, calculated by using time bottom (last row). Two independent coders assigned dependent Cox’s proportional hazards models that dated codes for each report of angina. In the rare event allowed for transitions during the follow up period, but of disagreement a third coder adjudicated. We defined a only to a more severe category of angina. Thus the report of angina at each date that new evidence became numbers of participants in the categories of angina in available, but we allocated only one code, the highest, tables 1 and 4 differ. We defined impaired SF-36 physi- within any 28 day period. For participants reporting cal functioning as below the lowest sex specific quartile Rose angina at follow up but not at the previous phase, ( < 86 for men and < 71 for women) and used logistic we used the mid-point date as the date of the report. regression to determine odds ratios of impaired physi- Outcomes: mortality, non-fatal myocardial cal functioning. infarction and physical functioning Almost all (99.9%) participants were flagged at the Results NHS Central Registry, which notified us of dates of death.
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