Sage Journals: Discover world-class research

Abstract

Background:

The prognostic significance of chest pain is well established in patients with coronary artery disease, but still ill defined in primary prevention. Therefore, the aim of our analysis was to assess the prognostic value of different forms of chest pain in a large cohort of primary care subjects under the conditions of contemporary modalities of care in primary prevention, including measurement of serum levels of the biomarker NT-pro-BNP.

Design:

We carried out a post-hoc analysis of the prospective DETECT cohort study.

Methods:

In a total of 5570 unselected subjects, free of coronary artery disease, within the 55,518 participants of the cross-sectional DETECT study, we assessed chest pain history by a comprehensive questionnaire and measured serum NT-pro-BNP levels. Three types of chest pain, which were any chest pain, exertional chest pain and classical angina, were defined. Major adverse cardiovascular events (MACEs = cardiovascular death, myocardial infarction, coronary revascularization procedures) were assessed during a 5-year follow-up period.

Results:

During follow-up, 109 subjects experienced a MACE. All types of reported chest pain were associated with an approximately three-fold increased risk for the occurrence of incident MACEs, even after adjusting for cardiovascular risk factors. Any form of reported chest pain had a similar predictive value for MACEs as a one-time measurement of NT-pro-BNP. However, adding a single measurement of NT-pro-BNP and the information on chest pain resulted in reclassification of approximately 40% of subjects, when compared with risk prediction based on established cardiovascular risk factors.

Conclusions:

In primary prevention, self-reported chest pain and a single measurement of NT-pro-BNP substantially improve cardiovascular risk prediction and allow for risk reclassification of approximately 40% of the subjects compared with assessing classical cardiovascular risk factors alone.

Keywords

Self-reported chest pain NT-pro-BNP risk prediction primary prevention

Get full access to this article

View all access options for this article.

References

Reddy

. Cardiovascular disease in non-Western countries. N Engl J Med 2004; 350: 2438–2440.

Heberden W. Commentaries on the History and Cure of Disease. London: TPayne, 1802.

Sekhri

Feder

Junghans

Hemingway

Timmis

. How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients. Heart 2007; 93: 458–463.

Giugliano

Lloyd-Jones

Camargo

Jr Makary

O'Donnell

. Association of unstable angina guideline care with improved survival. Arch Intern Med 2000; 160: 1775–1780.

Braunwald

Antman

Beasley

. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction–summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2002; 40: 1366–1374.

Bassand

Hamm

Ardissino

. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J 2007; 28: 1598–1660.

Sorlie

Cooper

Schreiner

Rosamond

Szklo

. Repeatability and validity of the Rose questionnaire for angina pectoris in the Atherosclerosis Risk in Communities Study. J Clin Epidemiol 1996; 49: 719–725.

LaCroix

Guralnik

Curb

Wallace

Ostfeld

Hennekens

. Chest pain and coronary heart disease mortality among older men and women in three communities. Circulation 1990; 81: 437–446.

Lampe

Whincup

Wannamethee

Ebrahim

Walker

Shaper

. Chest pain on questionnaire and prediction of major ischaemic heart disease events in men. Eur Heart J 1998; 19: 63–73.

10.

Erhardt

Herlitz

Bossaert

. Task force on the management of chest pain. Eur Heart J 2002; 23: 1153–1176.

11.

Bhopal RS, Bansal N, Fischbacher C, Brown H and Capewell S. Ethnic variations in chest pain and angina in men and women: Scottish Ethnicity and Health Linkage Study of 4.65 million people. Eur J Cardiovasc Prev Rehabil 2012; 19: 1250--1257.

12.

Zethelius

Berglund

Sundstrom

. Use of multiple biomarkers to improve the prediction of death from cardiovascular causes. N Engl J Med 2008; 358: 2107–2116.

13.

Wannamethee SG, Welsh P, Lowe GD, et al. N-terminal pro-brain natriuretic Peptide is a more useful predictor of cardiovascular disease risk than C-reactive protein in older men with and without pre-existing cardiovascular disease. J Am Coll Cardiol 58: 56–64.

14.

Wittchen

Glaesmer

Marz

. Cardiovascular risk factors in primary care: methods and baseline prevalence rates - the DETECT program. Curr Med Res Opin 2005; 21: 619–630.

15.

Rose

. The diagnosis of ischaemic heart pain and intermittent claudication in field surveys. Bull World Health Organ 1962; 27: 645–658.

16.

Lallukka

Manderbacka

Keskimaki

. Angina pectoris: relation of epidemiological survey to registry data. Eur J Cardiovasc Prev Rehabil 2011; 18: 621–626.

17.

National Institute for Health and Clinical Excellence (NICE). Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Clinical Guidance CG95, National Institute for Health and Clinical Excellence, London, 2010, http://guidanceniceorguk/CG95.

18.

James

Lindahl

Siegbahn

. N-terminal pro-brain natriuretic peptide and other risk markers for the separate prediction of mortality and subsequent myocardial infarction in patients with unstable coronary artery disease: a Global Utilization of Strategies To Open occluded arteries (GUSTO)-IV substudy. Circulation 2003; 108: 275–281.

19.

Pearson

Blair

Daniels

. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 2002; 106: 388–391.

20.

Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143–3421.

21.

Simper

Wang

Deb

. Endothelial progenitor cells are decreased in blood of cardiac allograft patients with vasculopathy and endothelial cells of noncardiac origin are enriched in transplant atherosclerosis. Circulation 2003; 108: 143–149.

22.

Wilson

D'Agostino

Levy

Belanger

Silbershatz

Kannel

. Prediction of coronary heart disease using risk factor categories. Circulation 1998; 97: 1837–1847.

23.

Pencina

D'Agostino

. Overall C as a measure of discrimination in survival analysis: model specific population value and confidence interval estimation. Stat Med 2004; 23: 2109–2123.

24.

Pencina

D'Agostino

Sr D'Agostino

Jr Vasan

. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med 2008; 27: 157–172; discussion 207–212.

25.

Jones

Rait

Falconer

Feder

. Systematic review: prognosis of angina in primary care. Fam Pract 2006; 23: 520–528.

26.

Buckley

Simpson

McLernon

Murphy

Hannaford

. Five year prognosis in patients with angina identified in primary care: incident cohort study. BMJ 2009; 339: b3058–b3058.

27.

Wang

Gona

Larson

. Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med 2006; 355: 2631–2639.

28.

de Lemos JA and Rohatgi A. Separating the contenders from the pretenders: competitive high-throughput biomarker screening in large population–based studies. Circulation 121: 2381–2383.

29.

Olsen

Hansen

Christensen

. N-terminal pro-brain natriuretic peptide, but not high sensitivity C-reactive protein, improves cardiovascular risk prediction in the general population. Eur Heart J 2007; 28: 1374–1381.

30.

Melander

Newton-Cheh

Almgren

. Novel and conventional biomarkers for prediction of incident cardiovascular events in the community. JAMA 2009; 302: 49–57.

31.

Blankenberg S, Zeller T, Saarela O, et al. Contribution of 30 biomarkers to 10-year cardiovascular risk estimation in 2 population cohorts: the MONICA, risk, genetics, archiving, and monograph (MORGAM) biomarker project. Circulation 121: 2388–2397.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.15 MB

Prognostic value of reported chest pain for cardiovascular risk stratification in primary care

Abstract

Background:

Design:

Methods:

Results:

Conclusions:

Keywords

Get full access to this article

References

Supplementary Material