The site o f current chest pain was coded in a hierarchical form at each questionnaire according to the codes shown in Figure 4.3. For example, a man who indicated the site o f pain as the sternum and the right chest would be coded in the first category ‘sternum ’. For Rose angina (Q) at least one o f the first two categories is required. For BRHS definite angina (Q), one o f the first
three categories is required (sternum or upper left chest). Among all men with exertional chest pain [angina (Q)], the distribution o f chest pain site was broadly similar at the four questionnaires. Pain was located over the sternum in approximately two thirds o f men (although this proportion was higher at Q l), but only an additional 2-4% reported pain in the left chest
together with the left arm. Approximately 15% o f men reported pain in the upper left chest but not in the previous two categories. Among the remainder o f men, the lower left chest was the most common site, followed by the right chest. Remaining sites (neck and upper arm pain without other sites) were infrequent. Therefore, the site o f exertional chest pain fulfilled the BRHS criteria for definite angina (Q) in approximately 85% o f men, while the Rose site criterion was fulfilled in about 70%.
Figure 4.4 shows the cumulative proportion o f men with angina (Q) who fulfilled each additional Rose criterion. O f all men with exertional chest pain, approximately 90% reported slowing or stopping in response to chest pain, 80% additionally reported relief o f pain on stopping, 70% additionally reported relief within 10 minutes, and 60% additionally had pain over the sternum or left anterior chest: these 60% fulfilled all criteria for definite angina (Q). Additional fulfilment o f the Rose chest pain site criterion reduced the proportion to about 50% o f all men with exertional chest pain.
Inquiry on chest pain frequency was restricted to Q l . O f 607 men with angina (Q) at Q l, 70.0% had experienced pain within the last month, while 35.2% experienced daily or weekly pain. Eight percent o f men with angina (Q) reported a single isolated episode o f pain. There was no difference between definite and possible angina (Q) in the proportion reporting recent (70.8% and 69.4% respectively) or frequent (36.1% and 34.5%) chest pain. Men with non-exertional chest pain at Q l were less likely to report recent (57.1%) or frequent (15.7%) episodes o f pain.
4.4.2 3 Prevalence of diagnosed CHD
The age-specific prevalences o f subject-reported CHD diagnoses [angina (DR), MI (DR), and CHD (DR)] are shown in Table 4.6. In each case there was a marked increase with age. The prevalence o f CHD (DR) rose from less than 2% among men aged 40-45 at Q l, to 27% among men aged 75-79 at Q96. This age gradient was considerably steeper than that seen for CHD symptoms (Table 4.5). The age-specific prevalences o f angina (DR) and MI (DR) were broadly similar to each other, although at older ages diagnosed angina was more common than diagnosed MI. O f all patients with prevalent diagnosed angina at each assessment, approximately 55% had uncomplicated angina [angina without Ml (DR)] (Table 4.6). The age specific prevalences o f angina (DR) tended to increase over time, but no clear trend over time was apparent for MI (DR), CHD (DR), and uncomplicated angina (DR).
4.4.2 4 CHD symptoms and diagnosed CHD
The proportion o f men with angina (Q) who reported a doctor diagnosis o f angina doubled from Q l (31.8%) to Q96 (60.5%). The prevalence o f diagnosed angina was consistently higher among men with definite angina (Q) than among those with possible angina (Q): 35.6% and 24.2% respectively at Q l; 44.0% and 32.0% at Q5; 65.2% and 50.0% at Q92; 65.5% and 52.7% at Q96 (p<0.01 at each questionnaire, logistic regression adjusted for age). Similar differences were apparent when all CHD (DR) was considered.
Figure 4.5 shows how the relationships between CHD symptoms and CHD diagnoses varied with age. Among men with angina (Q), the prevalence o f diagnosed angina rose greatly with age, from 11% among men aged 40-44 at Q l, to 72% among men aged 75-79 at Q96 [Figure 4.5 (i)]. This marked age-dependence was also apparent in the association between definite angina (Q) and diagnosed angina [Figure 4.5 (ii)]; PMI (Q) and diagnosed MI [Figure 4.5 (iii)]; CHD symptoms and diagnosed CHD overall [Figure 4.5 (iv)]. Although age largely explained the increase in CHD diagnosis prevalence from Q l to Q96 among men with CHD symptoms. Figures 4.5 (i) and (ii) suggest that there was also a secular trend in angina diagnosis: for men
with angina (Q) in the middle age range (55-65 years) there was an absolute increase o f about 10% in angina diagnosis prevalence from the first two assessments (Q1 and Q5) to the last two (Q92 and Q96).
Figure 4.6 presents the relationships between symptoms and diagnosis from the opposite perspective: the age-specific prevalence o f CHD symptoms among men with diagnosed CHD at each questionnaire. O f all men with diagnosed angina, the proportion with angina (Q) varied between 53% and 83% [Figure 4.6 (i)]. This proportion increased with age at Q l, but not at subsequent questionnaires. A much lower proportion (36-61%) o f men with diagnosed angina had chest pain conforming to definite angina (Q) [Figure 4.6 (ii)]. The proportion o f men with diagnosed MI who reported a history o f PMI (Q) showed a striking inverse association with age, falling from 95% among men aged 40-45 to less than 50% among men aged 75-79 [Figure 4.6 (iii)]. Among all men with a diagnosis o f CHD, the prevalence o f CHD symptoms fell from approximately 85% at Q l and Q5, to about 70% at Q92 and Q96 [Figure 4.6 (iv)].
Figure 4.7 shows the prevalence o f CHD by age group using a hierarchical classification in which diagnoses are ordered before symptoms. With increasing age, the prevalences o f diagnosed Ml and uncomplicated diagnosed angina increased markedly, but the prevalence o f angina (Q) without diagnosed CHD remained fairly stable at approximately 5 to 6%, and the prevalence o f PMI (Q) alone fell at each successive questionnaire. Men with undiagnosed CHD symptoms outnumbered those with diagnosed CHD at Q l and Q5, but the reverse was true at Q92 and Q96 among the older cohort.