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Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

BMJ 2008; 336 doi: (Published 08 May 2008) Cite this as: BMJ 2008;336:1058

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  1. Neha Sekhri, clinical research fellow1,
  2. Adam Timmis, professor of clinical cardiology1,
  3. Ruoling Chen, senior lecturer in epidemiology2,
  4. Cornelia Junghans, research fellow in epidemiology2,
  5. Niamh Walsh, statistician3,
  6. Justin Zaman, clinical research fellow in epidemiology2,
  7. Sandra Eldridge, professor of biostatistics3,
  8. Harry Hemingway, professor of clinical epidemiology2,
  9. Gene Feder, professor of primary health care4
  1. 1Cardiac Directorate, Barts and the London NHS Trust, London
  2. 2Department of Epidemiology and Public Health, University College London Medical School, London
  3. 3Centre for Health Sciences, Barts and the London, Queen Mary’s School of Medicine and Dentistry, Queen Mary, University of London, London
  4. 4Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA
  1. Correspondence to: G Feder gene.feder{at}
  • Accepted 26 March 2008


Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates.

Design Multicentre cohort with five year follow-up.

Setting Six ambulatory care clinics in England.

Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method.

Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.

Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.

Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.


  • In memory of Sarah Cotter (1949-2004), who worked on an earlier version of this analysis.

  • Contributors: All authors contributed to the design of this study. NS, NW, CJ, and RC carried out the analyses. GF wrote the first draft of the paper and is guarantor, and all authors contributed to revisions.

  • Funding: NHS service delivery and organisation research and development programme.

  • Competing interests: None declared.

  • Ethical approval: Trent multicentre research ethics committee and all local research ethics committees.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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