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Risk score for predicting death, myocardial infarction, and stroke in patients with stable angina, based on a large randomised trial cohort of patients

BMJ 2005; 331 doi: (Published 13 October 2005) Cite this as: BMJ 2005;331:869
  1. Tim C Clayton, lecturer1,
  2. Jacobus Lubsen, professor (jlubsen{at},
  3. Stuart J Pocock, professor1,
  4. Zoltán Vokó, assistant professor4,
  5. Bridget-Anne Kirwan, director3,
  6. Keith A A Fox, professor5,
  7. Philip A Poole-Wilson, professor6 on behalf of the ACTION investigators
  1. 1 Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. 2 Department of Epidemiology and Biostatistics, Erasmus Medical Centre, 3000 DR Rotterdam, Netherlands
  3. 3 SOCAR Research SA, PO Box 2564, CH-1260 Nyon 2, Switzerland
  4. 4 School of Public Health, University of Debrecen, H-4028 Debrecen, Hungary
  5. 5 Cardiovascular Research Unit, Edinburgh University, Edinburgh EH16 4SB
  6. 6 Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London SW3 6LY
  1. Correspondence to: J Lubsen
  • Accepted 10 August 2005


Objective To derive a risk score for the combination of death from all causes, myocardial infarction, and disabling stroke in patients with stable symptomatic angina who require treatment for angina and have preserved left ventricular function.

Design Multivariate Cox regression analysis of data from a large multicentre trial.

Setting Outpatient cardiology clinics in western Europe, Israel, Canada, Australia, and New Zealand.

Participants 7311 patients with all required data available.

Main outcome measure Death from any cause or myocardial infarction or disabling stroke during a mean follow-up of 4.9 years.

Results 1063 patients either died from any cause or sustained myocardial infarction or disabling stroke. The five year risk of this composite ranged from 4% for patients in the lowest tenth of risk to 35% for patients in the highest tenth. The risk score combines 16 routinely available clinical variables (in order of decreasing contribution): age, left ventricular ejection fraction, smoking, white blood cell count, diabetes, casual blood glucose concentration, creatinine concentration, previous stroke, at least one angina attack a week, coronary angiographic findings (if available), lipid lowering treatment, QT interval, systolic blood pressure ≥ 155 mm Hg, number of drugs used for angina, previous myocardial infarction, and sex. Fitting the same model separately to all cause death, myocardial infarction, and stroke gave similar results. The risk score did not seem to predict the nature of the event (death in 39%, myocardial infarction in 46%, and disabling stroke in 15%) or the incidence of angiography or revascularisation, which occurred in 29% of patients.

Conclusion This risk score is an objective aid in deciding on further management of patients with stable angina with the aim of reducing serious outcome events. The score can also be used in planning future trials.


  • Contributors TCC carried out the statistical analysis. JL, SJP, B-AK, and ZV wrote the paper. All authors were involved in the design of the analysis, interpretation of the results, and improvements to the manuscript. All authors except ZV were also involved in the ACTION trial. SJP is the guarantor.

  • Funding The ACTION trial was supported by Bayer Healthcare AG, Wuppertal, Germany.

  • Competing interests The ACTION study was carried out by an independent steering committee and research group. JL, KAAF and PAP-W have served as consultants to, or received travel expenses, payment for speaking at meetings, or funding for research from, other pharmaceutical companies. BAK and JL are full time employees of SOCAR Research SA, which man-aged the study.

  • Ethical approval Not required.

  • Accepted 10 August 2005
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