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Prognosis estimates need to be for all patients with angina
- Melvyn M Jones (29 March 2006)
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Melvyn M Jones, Senior Lecturer in General Practice Dept of Primary Care & Population Sciences, Royal Free & UCL Medical School, London N19 5LW
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I welcome Daly’s work addressing the neglected area of the contemporary prognosis of angina. (1) However I believe there is an important flaw in the study. The authors state that they aimed “to study a representative population with stable angina, not just pre-selected patients admitted to hospital” and yet they then state that they recruited patients on “new presentation to a cardiologist as an out patient”. (2) I believe that there will be an important selection bias between people with angina in primary and secondary care. Historically few patients with angina have been referred from primary care (3) This may be changing at least in the UK with the new UK GP contract (4) Data arising from the Quality and Outcome framework (QOF) monitoring system (5) of the new GP contract would suggest there is still a large pool of patients with angina in the community, as it indicates a coronary heart disease prevalence of 3.6% (1,893,184) of the population of England. Previous work (6) has suggested that approximately 50% of those labelled with CHD in primary care will have angina, suggesting approximately 900,000 sufferers with angina in England. QOF data also reports there were 174,000 incident cases of angina in England (over the 2 year window) which gives a new incidence rate of angina of 0.33% (0.17% pa). (7) There are problems with these data, but the consistency of prevalence across primary care trusts suggests these figures are of value. This new data would suggest with respect to angina, that there is a considerable clinical iceberg. Most patients experiencing angina are not visible from the perspective of a cardiology out patients. It is also recognised that some people with angina like symptoms do not consult at all. (8) I believe therefore that any prognostic scores based on this hospital based population, while useful, should be treated with caution. Prognosis of angina can only ever be estimated if a representative population of sufferers are studied. Melvyn Jones
Reference List (1)Daly CA, De Stavola B, Sendon JLL, Tavazzi L, Boersma E, Clemens F et al. Predicting prognosis in stable angina--results from the Euro heart survey of stable angina: prospective observational study. BMJ 2006; 332(7536):262-267. (2)Daly CA, Clemens F, Sendon JLL, Tavazzi L, Boersma E, Danchin N et al. The clinical characteristics and investigations planned in patients with stable angina presenting to cardiologists in Europe: from the Euro Heart Survey of Stable Angina. European Heart Journal 2005; 26(10):996- 1010. (3)Clarke KW, Gray D, Hampton JR. Implication of prescriptions for nitrates: 7 year follow up of patients treated for angina in general practice. Br Heart J 1994; 71(1):38-40. (4)New GMS contract. 2003. BMA / NHS Confederation. Ref Type: Generic (5) Lester H, Sharp D, Hobbs FDR, Lakhani M. The quality and outcomes framework of the GMS contract: a quiet evolution for 2006. Br J Gen Pract 2006; 56(525):244-246. (6)Campbell NC, Ritchie LD, Thain J, Deans HG, Rawles JM, Squair JL. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart 1998; 80:447-452. (7) The Health and Social Care Information Centre (NHS). Quality and Outcomes Framework (QOF) for April 2004 - March 2005, England http://www.icservices.nhs.uk/qofdocuments/QOF0405_SHAs_Prevalence.xls . 2006. (8)Owen Smith V, Hannaford PC, Elliot AM. Increased mortality among women with Rose angina who have not presented with ischaemic heart disease. British Journal of General Practice 2003; 53:784-789. Competing interests: I am researching prognosis in primary care settings |
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