CORONARY ARTERY DISEASE
How effective are rapid access chest pain clinics? Prognosis
of incident angina and non-cardiac chest pain in 8762
N Sekhri, G S Feder, C Junghans, H Hemingway, A D Timmis
............................................................... ............................................................... .....
See end of article for
A D Timmis, London Chest
Hospital, Barts and The
London NHS Trust, Bonner
Road, London E2 9JX, UK;
Accepted 8 June 2006
Published Online First
21 June 2006
Heart 2007;93:458–463. doi: 10.1136/hrt.2006.090894
Objective: To determine whether rapid access chest pain clinics are clinically effective by comparison of
coronary event rates in patients diagnosed with angina with rates in patients diagnosed with non-cardiac
chest pain and the general population.
Design: Multicentre cohort study of consecutive patients with chest pain attending the rapid access chest pain
clinics (RACPCs) of six hospitals in England.
Participants: 8762 patients diagnosed with either non-cardiac chest pain (n=6396) or incident angina
without prior myocardial infarction (n=2366) at first cardiological assessment, followed up for a median of
2.57 (interquartile range 1.96–4.15) years.
Main outcome measures: Primary end point—death due to coronary heart disease (International
Classification of Diseases (ICD)10 I20–I25) or acute coronary syndrome (non-fatal myocardial infarction
(ICD10 I21–I23), hospital admission with unstable angina (I24.0, I24.8, I24.9)). Secondary end points—all-
cause mortality (ICD I20), cardiovascular death (ICD10 I00–I99), or non-fatal myocardial infarction or non-
fatal stroke (I60–I69).
Results: The cumulative probability of the primary end point in patients diagnosed with angina was 16.52%
(95% confidence interval (CI) 14.88% to 18.32%) after 3 years compared with 2.73% (95% CI 2.29% to
3.25%) in patients with non-cardiac chest pain. Coronary standardised mortality ratios for men and women
with angina aged ,65 years were 3.52 (95% CI 1.98 to 5.07) and 4.39 (95% CI 1.14 to 7.64). Of the 599
patients who had the primary end point, 194 (32.4%) had been diagnosed with non-cardiac chest pain.
These patients were younger, less likely to have typical symptoms, more likely to be south Asian and more
likely to have a normal resting electrocardiogram than patients with angina who had the primary end point.
Conclusion: RACPCs are successful in identifying patients with incident angina who are at high coronary risk,
but there is a need to reduce misdiagnosis and improve outcomes in patients diagnosed with non-cardiac
chest pain who accounted for nearly one third of cardiac events during follow-up.
chest pain clinics (RACPCs) are now widely established on the
basis of the assumption that one-stop cardiological assessment
can successfully identify patients with angina who are
considered to be at high risk of adverse cardiovascular
outcomes. It is implicit in this that patients diagnosed with
non-cardiac chest pain can be safely excluded from further
cardiac investigation and treatment. However, the validity of
this assumption is unknown because the prognosis of incident
angina and non-cardiac chest pain in patients with previously
undiagnosed symptoms has not been defined. Previous studies
have been limited by small size and short periods of follow-up.5–
8We have studied the prognosis of a large cohort of patients
referred from primary care with chest pain, none of whom had
had previous cardiological assessment. Our primary objective
was to assess the clinical effectiveness of RACPCs by
determining the extent to which diagnoses of angina and
non-cardiac chest pain validate the prognostic assumptions
that have led to their widespread introduction in the UK.
ngina is the most common initial manifestation of
coronary heart disease1–3and accounts for an estimated
1% of annual health expenditure in the UK.4Rapid access
Consecutive patients attended six RACPCs in which cardiolo-
gical consultation was provided within 2 weeks of referral from
primary care according to the imperatives of the UK National
Service Framework for coronary heart disease.9The purpose of
the clinics was to identify patients with angina to initiate
appropriate treatment, including secondary prevention with
aspirin and b-blockers, and to carry out cholesterol measure-
ment with a view to starting statin treatment, according to
Data on 11082 patients were
electronically recorded from 2 January 1996 to 31 December
2002 using identical databases, details of which have been
reported previously.11We excluded re-attendances during the
study period (n=448), patients without chest pain (n=291),
patients diagnosed with acute coronary syndromes on the day
of visit (n=246), patients who reported previously diagnosed
coronary heart disease or revascularisation procedure (n=579),
patients for whom a diagnosis was either not entered (n=132)
or not identified as angina or non-cardiac chest pain (n=83),
those with undefined ethnic group (n=134), patients with
missing data (n=367) and those who were not traced by the
Office for National Statistics12or the NHS-wide clearing
system13(n=40). The remaining 8762 patients with complete
data and follow-up constituted the study group.
Clinical data were systematically recorded and included age,
sex, ethnicity, clinical descriptors of chest pain (duration of
Abbreviations: ECG, electrocardiogram; RACPCs, rapid access chest
pain clinics; SMR, standardised mortality ratio
symptoms before attendance, character, site and radiation of
chest pain, duration of an episode, precipitating factors and
relief with glyceryl trinitrate), smoking status, history of
hypertension, diabetes, pulse rate, systolic blood pressure,
drugs and follow-up plan on discharge. Twelve-lead resting
electrocardiograms (ECGs) were recorded as normal or abnor-
mal, respectively, depending on assessment of rhythm, con-
duction, and the absence or presence of regional ST segment or
T wave changes, left-ventricular hypertrophy and Q waves.
Exercise treadmill tests were carried out at the discretion of
clinicians in 58% of patients. Reasons for not carrying out an
ECG treadmill test were recorded as follows: resting ECG
abnormalities or other comorbidities (16%), not indicated
(26%), in whom median probability of coronary artery disease
was 18.6% (interquartile range (IQR) 8.4–32.4%). Diagnosis of
the cause of chest pain, either angina or non-cardiac chest pain,
was based on the clinical assessment of the clinician who
recorded it at the end of the consultation.
Patients were flagged for mortality with the Office for National
Statistics (to 25 April 2005), and for hospital admissions and
procedures with the NHS-wide clearing system (to 23
December 2003). Successful matching was achieved in 99.5%
of the cohort. Causes of death were defined by the World
Health Organization International Classification of Diseases (ICD10
codes). Among patients undergoing hospital admission during
the follow-up period, the primary discharge diagnosis was used
to define events.
Main outcome measures
The primary end point was a composite of death due to
coronary heart disease (ICD10 I20–I25) or acute coronary
syndrome (non-fatal myocardial infarction (ICD10 I21–I23)
and hospital admission with unstable angina (I24.0, I24.8,
I24.9)). Secondary end points were all-cause mortality (ICD
I20), cardiovascular death (ICD10 I00–I99) or non-fatal
myocardial infarction (ICD10 121–123) or hospital admission
with unstable angina (I24.0, I24.8, I24.9) or non-fatal stroke
Ethical approval was obtained from the multiregional ethics
committee (MREC/02/04/095). Permission was given by the
National Patient Information Advisory Group14to link anon-
ymised datasets without individual patient consent.
Patients with angina and non-cardiac chest pain were
compared using x2and t tests for proportions and distributions,
respectively. We calculated Kaplan–Meier product limits for the
cumulative probability of reaching an end point and used the
log rank test for evidence of a statistically significant difference
between the groups. Time was measured from the first clinic
visit to the outcome of interest. Cox regression analysis was
used to estimate hazard ratios for the effect of angina on
outcome in age-adjusted and fully adjusted models, based on
covariates associated (p,0.05) with the outcome of interest.
We used STATA V.8.0 for all the analyses.
Standardised mortality ratios
Standardised mortality ratios (SMRs) were calculated as the
ratio of observed mortality within the study group to expected
mortality based on data available from the Office for National
Statistics. SMRs for all-cause mortality were calculated for each
year of the study, taking into account the exact time each
patient was in the study and using 1-year age bands. The
reference death rates were for England for the same year,
except for 2003 and 2004, for which the death rates were not
available and the 2002 death rates were used. The reference
death rates for death due to coronary heart disease and other
disease groups are given in 10-year age blocks, so we used
linear interpolation to derive death rates for each year of age.
SMRs for coronary heart disease and other disease groups were
calculated using the same method as for all-cause mortality.
Table 1 summarises the baseline characteristics of patients
diagnosed with angina or non-cardiac chest pain.
Patients diagnosed with angina were older and more likely to
be men than patients diagnosed with non-cardiac chest pain.
Among patients with angina, 58% were referred for further
outpatient cardiological assessment, with a total of 35%
undergoing angiography during follow-up, of whom 43% had
a revascularisation procedure. Only 18% were referred back to
their primary care physician after a single clinic visit compared
with 89% of patients with non-cardiac chest pain.
Prognosis of angina and non-cardiac chest pain
Figure 1 shows the Kaplan–Meier survival curves for patients
with and without angina.
During a median follow-up of 2.57 (IQR 1.96–4.15) years, all
outcomes were more frequent for patients with angina than for
patients with non-cardiac chest pain. In patients with angina, the
cumulative probability of the primary end point was 8.62% (95%
CI 7.56% to 9.83%) after 1 year, rising to 16.52% (95% CI 14.88%
to 18.32%) after 3 years. This compares with cumulative
probabilities for the primary end point of 0.83% (95% CI 0.63%
to 1.08%) after 1 year and 2.73% (95% CI 2.29% to 3.25%) after
3 years in patients with non-cardiac chest pain. In the 501
patients with missingbaseline data, rates of theprimary endpoint
were not significantly different from those in the main cohort.
Predictive accuracy of diagnosis for the primary end
Among the 599 patients with the primary end point, 194
(32.4%) had been diagnosed with non-cardiac chest pain.
Compared to patients with angina who reached the primary
end point (n=405), those with non-cardiac chest pain
(n=194) were younger, a higher proportion were south
Asians, .80% had normal resting electrocardiograms and a
substantially lower proportion had typical symptoms and an
abnormal exercise treadmill test. Multivariate associations with
the primary end point in patients diagnosed with non-cardiac
chest pain were age, male sex, south Asian ethnicity, diabetes,
typical symptoms and abnormal ECG (table 2).
Comparison with the general population
Table 3 gives the SMRs in patients with angina and non-cardiac
In patients with angina, coronary SMRs were increased in men
(3.52 (95% CI 1.98 to 5.07)) and women (4.39 (95% CI 1.14 to
7.64)) ,65 years, but not in older patients. In patients with non-
cardiac chest pain, coronary SMRs were lower than in the general
population in older patients, but not in men (1.15 (95% CI 0.57 to
1.73)) and women (1.96 (95% CI 0.68 to 3.24)) ,65 years.
This multicentre study has shown that among patients with
undifferentiated chest pain assessed in RACPCs, those diag-
nosed with angina have a substantially higher risk of death due
to coronary heart disease or non-fatal acute coronary syndrome
than patients diagnosed with non-cardiac chest pain and the
Prognosis of incident angina and non-cardiac chest pain459
general population. The data confirm the prognostic validity of
differential diagnosis within RACPCs. Our finding that 32.4% of
all events during follow-up occurred in patients diagnosed with
non-cardiac chest pain highlights the need to reduce mis-
diagnosis and identify all who might benefit from secondary
This is the first large, multicentre consecutive series of
ambulatory patients with new, undifferentiated chest pain,
allowing estimates of prognosis in women and men. Angina
was diagnosed in 27% of patients, and in this group cumulative
rates of death due to coronary heart disease or acute coronary
syndromes were high, estimated at 8.62% after 1 year and
cardiac chest pain, in those who did and did not subsequently experience the primary end
Baseline characteristics among consecutive patients diagnosed with angina or non-
Angina group (n=2366) Non-cardiac group (n=6396)
With 1 end point*,
Without 1 end
With 1 end point*,
Without 1 end
Mean (SD) age (years)62 (11) 62 (11) 56 (11)51 (12)
Males 240 (59%) 1114 (57%)111 (57%) 3129 (50%)
Ethnicity, n (%)
Risk factor, n (%)
Duration of chest pain?, n (%)
Character of chest pain, n (%)
Resting ECG, n (%)
Exercise treadmill test, n (%)
Not done, not indicated
Not done, other reason
Mean (SD) systolic blood
pressure (mm Hg)
Heart rate (beats/min)
148 (21) 147 (21)143 (23)138 (20)
77 (13)76 (12) 77 (13)77 (12)
Medication on discharge, n (%)
Disposal1, n (%)
Discharged to primary care
CABG, coronary artery bypass graft; ECG, electrocardiogram; PTCA, percutaneous transluminal coronary angioplasty.
*1 (Primary) end point—death due to coronary heart disease or acute coronary syndrome.
?Duration of chest pain before attendance at the clinic.
`Percentage of patients not prescribed a statin but in whom a cholesterol check was recommended (data available for
1Data available for 8689 patients.
460Sekhri, Feder, Junghans, et al
16.52% after 3 years. Our finding of a poor prognosis for
patients with incident angina, none of whom had a history of
myocardial infarction, emphasises the importance of early
diagnosis within RACPCs and contrasts with findings in recent
trials of chronic stable angina, ACTION (A CHF Trial
Investigating Outcomes of Exercise Training)15and PEACE
(Prevention of Events with Angiotensin-converting Enzyme
Inhibition)16reporting annual mortalities of 1.5% (95% CI 1.4%
to 1.7%) and 1.7% (95% CI 1.5% to 1.9%) compared with 3.1%
(95% CI 2.6% to 3.5%) in our registry population. The trialists’
conclusions that angina has a good prognosis,15with risk
reduced to normal levels with contemporary treatment,17may
partly reflect the selection bias in the patients they recruited,
which comprised stable patients in secondary or tertiary care
settings. Similarly, 75% of patients in the Euro Heart survey18of
stable angina had had symptoms for .6 months before their
first cardiological assessment and are different from the
patients in our study with incident angina, many of whom
were within 4 weeks and most within 6 months of symptom
onset, suggesting recent plaque instability and predisposition to
ischaemic events.19 20Underuse of secondary prevention drugs
may also have contributed to the high event rates we observed,
and although rates of aspirin and b-blocker treatment in
patients in our study diagnosed with angina were similar to
those reported in the Euro Heart Survey, only 28% were
prescribed statins at this first cardiological consultation. This is
lower than the entry treatment rates for angina trial partici-
pants, many of whom had had prior myocardial infarction and
full cardiological investigation over many visits, but exceeds the
treatment rates reported for patients with ischaemic heart
disease in primary care settings.21More than 80% of our
patients with angina did undergo further cardiological follow-
up and although most probably came to receive statins, it is a
limitation of our study that we do not know what proportion
Patients diagnosed with non-cardiac chest pain in our study
had a lower event rate, but accounted for almost one third of all
primary end points. This is a cause for concern, because these
patients had been assessed for coronary disease in the RACPCs
and might therefore be expected to exhibit a distinctly lower
coronary mortality than the general population. We found
evidence for this in older patients diagnosed with non-cardiac
chest pain, but not in patients aged ,65 years for whom SMRs
were not significantly different from the general population.
bottom of each graph. *Hazard ratio (HR) adjusted for age only. ?HR adjusted for sex, age, ethnicity, diabetes, smoking status, heart rate, character of chest
pain and resting ECG. CHD, coronary heart disease.
Kaplan–Meier survival curves for patients with and without angina. Numbers at risk at beginning of each year of follow-up are displayed at the
Prognosis of incident angina and non-cardiac chest pain461
Probably most of these patients, who were told they did not
have angina, but then had a coronary event, were misdiagnosed
at the initial assessment, perhaps because they were younger
than patients diagnosed with angina, fewer had typical
symptoms and most had normal resting ECGs. Among patients
diagnosed with non-cardiac chest pain, coronary event rates fell
below current thresholds for secondary prevention treatment,10
but we identified subgroups in whom hazard ratios for the
primary end point were increased by >50%. These included
patients with diabetes, for whom secondary prevention treat-
ment is already recommended,22but also south Asians and
patients with ECG abnormalities who might benefit from more
aggressive preventive strategies in RACPCs. Although clinical
factors signal a heightened risk among subgroups diagnosed
with non-cardiac chest pain, there is now a need for research to
identify the methods for improving diagnostic precision. This
may entail a better understanding of existing measures—for
example, by development and validation of risk scores in this
population, as well as consideration of the incremental
prognostic or diagnostic value of serological testing23and non-
invasive coronary imaging.24 25Unlike myocardial infarction,26
there is no internationally agreed standard for defining the
presence or absence of angina.
This is the first large multicentre study to evaluate the
effectiveness of RACPCs by examining coronary outcomes in
relationship to clinical diagnosis and mortality in the general
population. There have been no previous outcome studies of
other models of ambulatory chest pain assessment, particularly
conventional cardiology outpatient clinics or chest pain assess-
ment units. Our conclusions about the adverse prognosis of
angina are consistent with those of a large population-based
outcome study from Finland,27but are limited to those patients
selected for referral by their primary care physicians, and
generalisation to chest pain in the community requires caution.
Additional limitations relate to ethical constraints that prohib-
ited the documentation of ongoing secondary prevention
treatment during follow-up, and also the inevitable restriction
imposed on baseline covariates by the data that was recorded.
For example, a reliable history of hyperlipidaemia was
unavailable, and we excluded from analysis family history of
coronary disease as it was not clear whether it related to history
of premature death in first-degree relatives.
Standardised mortality ratios (to April 2004) in patients diagnosed with angina and non-cardiac chest pain (n=8762)
Angina group Non-cardiac group
Male FemaleMale Female
O/ESMR (95% CI) O/ESMR (95% CI) O/ESMR (95% CI)O/E SMR (95% CI)
CHD (ICD 10 I20–I25)
1.83 (1.26 to 2.39)
0.87 (0.68 to 1.05)
1.05 (0.86 to 1.24)
1.78 (1.00 to 2.56)
0.85 (0.60 to 1.09)
1.01 (0.76 to 1.25)
1.00 (0.73 to 1.26)
0.73 (0.52 to 0.94)
0.85 (0.68 to 1.02)
1.21 (0.85 to 1.57)
0.51 (0.32 to 0.71)
0.80 (0.61 to 0.98)
3.52 (1.98 to 5.07)
1.62 (1.09 to 2.16)
2.03 (1.49 to 2.56)
4.39 (1.14 to 7.64)
1.76 (0.95 to 2.58)
2.13 (1.29 to 2.96)
1.15 (0.57 to 1.73)
0.71 (0.29 to 1.12)
0.92 (0.57 to 1.28)
1.96 (0.68 to 3.24)
0.31 (0.00 to 0.65)
0.85 (0.37 to 1.32)
1.04 (0.77 to 1.31)
0.62 (0.51 to 0.73)
0.70 (0.60 to 0.80)
1.19 (0.81 to 1.57)
0.64 (0.50 to 0.78)
0.79 (0.65 to 0.93)
0.88 (0.72 to 0.83)
0.83 (0.68 to 0.98)
0.81 (0.71 to 0.91)
0.92 (0.74 to 1.10)
0.56 (0.43 to 0. 69)
0.76 (0.65 to 0.87)
O, observed mortality; CHD, coronary heart disease; E, expected mortality; ICD, International Classification of Diseases; SMR, standardised mortality rate.
6396 patients diagnosed with non-cardiac chest pain
Predictors of death due to coronary heart disease or acute coronary syndrome in
CHD death or acute coronary syndrome (n=194)
(95% CI) p Value
(95% CI) p Value
Black v white
SA v white
History of hypertension
Systolic blood pressure
Diabetes v none
Typical v non-specific
Atypical v non-specific
Duration of symptoms
.1 month v (1 month
Heart rate, 10 beats/min
Abnormal ECG result
1.41 (1.06 to 1.87)
1.47 (1.32 to 1.65)
1.36 (1.02 to 1.81)
1.46 (1.29 to 1.64)
0.63 (0.35 to 1.12)
1.73 (1.27 to 2.35)
1.22 (0.91 to 1.65)
1.00 (0.99 to 1.01)
1.30 (0.95 to 1.80)
2.49 (1.76 to 3.52)
0.000 0.58 (0.32 to 1.04)
1.51 (1.10 to 2.08)
2.14 (1.49 to 3.09)
2.03 (1.17 to 3.54)
1.04 (0.75 to 1.45)
1.01 (0.76 to 1.35)
0.050 2.12 (1.21 to 3.70)
1.07 (0.76 to 1.49)
0.97 (0.86 to 1.09)
1.66 (1.14 to 2.42)
1.62 (1.10 to 2.36)
CHD, coronary heart disease; ECG, electrocardiogram; SA, South Asians.
*Age is univariable.
?Adjusted for all variables in the table apart from history of hypertension, systolic blood pressure, current smoking,
duration of symptoms and heart rate.
462Sekhri, Feder, Junghans, et al
Conclusion Download full-text
One-stop cardiological assessment in RACPCs successfully
identifies patients with incident angina who are at substantially
non-cardiac chest pain and the general population. However,
.70% of patients attending these clinics were diagnosed with
non-cardiac chest pain, and our data have exposed misdiagno-
sis in a minority who were not appropriately treated. We need
to improve the diagnosis and treatment of ambulatory patients
when they first present with chest pain, to reduce coronary
We thank and remember the late Dr Sarah Cotter for her help with the
statistical analysis and manuscript preparation. We also thank Dr
Joanne Morris (Research & Development, Newham University
Hospital) for administrative help and Dr Ranjadayalan (Newham
University hospital), Dr Myers (Blackburn Royal Infirmary), Dr Best
(Burnley General Hospital), Dr Curzen (Manchester Royal Infirmary),
Dr Kadr and Dr Koh (Oldchurch hospital) and Dr Culling (Kingston
General Hospital), for cooperating in this multicentre study and giving
us permission to include their patients, and Mr Roger Stafford, the
database manager, for his help.
N Sekhri, Newham University Hospital, London, UK
G S Feder, A D Timmis, Barts and The London Queen Mary’s School of
Medicine and Dentistry, London, UK
C Junghans, H Hemingway, Department of Epidemiology and Public
Health, UCL Medical School, London, UK
Funding: This study was funded by the National Health Service (NHS)
Service Delivery and Organisation (SDO) research and development
programme, to which interim progress reports were submitted. The funding
body was not involved in study design or analysis.
Competing interests: None declared.
ADT, GSF, HH and NS were responsible for the design and management
of this study. NS and CJ were responsible for the statistical analysis. All the
authors participated in the preparation of the manuscript.
1 Kannel WB, Feinleib M. Natural history of angina pectoris in the Framingham
study. Prognosis and survival. Am J Cardiol 1972;29:154–63.
2 Sutcliffe SJ, Fox KF, Wood DA, et al. Incidence of coronary heart disease in a
health authority in London: review of a community register. BMJ 2003;326:20.
3 Kentsch M, Rodemerk U, Gitt AK, et al. Angina intensity is not different in
diabetic and non-diabetic patients with acute myocardial infarction. Z Kardiol
4 Stewart S, Murphy N, Walker A, et al. The current cost of angina pectoris to the
National Health Service in the UK. Heart 2003;89:848–53.
5 Gandhi MM, Lampe FC, Wood DA. Incidence, clinical characteristics, and short-
term prognosis of angina pectoris. Br Heart J 1995;73:193–8.
6 Duncan B, Fulton M, Morrison SL, et al. Prognosis of new and worsening angina
pectoris. BMJ 1976;1:981–5.
7 Davie AP, Caesar D, Caruana L, et al. Outcome from a rapid-assessment chest
pain clinic. QJM 1998;91:339–43.
8 Byrne J, Murdoch D, Morrison C, et al. An audit of activity and outcome from a
daily and a weekly ‘‘one stop’’ rapid assessment chest pain clinic. Postgrad Med J
9 Department of Health. National Service Framework for Coronary Heart Disease:
modern standards and service models. London: Department of Health, 2000.
10 British Cardiac Society. Joint British recommendations on prevention of coronary
heart disease in clinical practice. British Cardiac Society, British Hyperlipidaemia
Association, British Hypertension Society, endorsed by the British Diabetic
Association. Heart 1998;80(Suppl 2):S1–29.
11 Ray S, Archbold RA, Preston S, et al. Computer-generated correspondence for
patients attending an open-access chest pain clinic. J R Coll Physicians Lond
12 Office for National Statistics. A brief history of the ONS. http://
www.bized.ac.uk/dataserv/ons/onshistory.htm (accessed 15 Sept 2006).
13 Anon. NHS-wide clearing system. http://www.connectingforhealth.nhs.uk/
nwcs/ (accessed 15 Sept 2006).
14 Anon. Patient Information Advisory Group. http://
www.advisorybodies.doh.gov.uk/piag/ (accessed 15 Sept 2006).
15 Poole-Wilson PA, Lubsen J, Kirwan BA, et al. Effect of long-acting nifedipine on
mortality and cardiovascular morbidity in patients with stable angina requiring
treatment (ACTION trial): randomised controlled trial. Lancet 2004;364:849–57.
16 Braunwald E, Domanski MJ, Fowler SE, et al. Angiotensin-converting-enzyme
inhibition in stable coronary artery disease. N Engl J Med 2004;351:2058–68.
17 Pitt B. ACE inhibitors for patients with vascular disease without left ventricular
dysfunction—may they rest in PEACE? N Engl J Med 2004;351:2115–17.
18 Daly CA, Clemens F, Sendon JL, 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. Eur Heart J
19 Shah PK. Mechanisms of plaque vulnerability and rupture. J Am Coll Cardiol
20 Abrams J. Chronic stable angina. N Engl J Med 2005;352:2524–33.
21 Hippisley-Cox J, Coupland C. Effect of combinations of drugs on all cause
mortality in patients with ischaemic heart disease: nested case-control analysis.
22 Collins R, Armitage J, Parish S, et al. MRC/BHF Heart Protection Study of
cholesterol-lowering with simvastatin in 5963 people with diabetes: a
randomised placebo-controlled trial. Lancet 2003;361:2005–16.
23 Kragelund C, Gronning B, Kober L, et al. N-terminal pro-B-type natriuretic
peptide and long-term mortality in stable coronary heart disease. N Engl J Med
24 Mollet NR, Cademartiri F, Nieman K, et al. Multislice spiral computed
tomography coronary angiography in patients with stable angina pectoris. J Am
Coll Cardiol 2004;43:2265–70.
25 Schmermund A, Denktas AE, Rumberger JA, et al. Independent and incremental
value of coronary artery calcium for predicting the extent of angiographic
coronary artery disease: comparison with cardiac risk factors and radionuclide
perfusion imaging. J Am Coll Cardiol 1999;34:777–86.
26 European Society of Cardiology/American College of Cardiology. Myocardial
infarction redefined—a consensus document of the Joint Committee for the
redefinition of myocardial infarction. Eur Heart J 2000;21:1502–13.
27 Hemingway H, McCallum A, Shipley M, et al. Incidence and prognostic
implications of stable angina pectoris among women and men. JAMA
Prognosis of incident angina and non-cardiac chest pain463