Prognosis of angina with and without a diagnosis: 11 year follow up in the Whitehall II prospective cohort study
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7420.895 (Published 16 October 2003) Cite this as: BMJ 2003;327:895
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Sir,-
Colleagues Hemingway et al. (BMJ 2003;327:895-8) have increased out
understanding on the impact of coronary heart disease, especially if the
condition goes undiagnosed. My concern is whether this information has
been obtained in an ethically transparent way. Many of their subjects had
the condition already in 1985, but did not know about it. When did the
authors learn about the diagnoses? The article does not state when the
data was analyzed nor whether the study was approved by an ethics
committee.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Biophysical Semeiotics is really useful in order to bed-side recognizing
heart ischaemic disease, even before its onset, i.e., "real risk" of
coronary artery disease, as I wrote recently also in the 3rd International
Congress of Cardiology in Internet, organized by FAC, Argentine Cardiology
Federation: URL, http://www.fac.org.ar/tcvc/marcoesp/marcos.htm.
It is well known that patients, involved by risk of CAD or with CAD, may
have no symptoms at all over years or decades, and that the
electrocardiographic features of ischaemia may be induced by exercise
without accompaning angina (1). (See "Coronary artery disease, in my site
HONCode, N° 233736, http://digilander.libero.it/semeioticabiofisica; URL
http://digilander.libero.it/semeioticabiofisica/Documenti/Eng/Cardiopati...).In
other words, we need a clinical tool reliable in rapid detecting both the
risk of CAD, clinically silent, and CAD, also in initial asymptomatic
stage. With the aid of biophysical semeiotics (1) I examined 300
individuals with family history positive for CAD, and 250 patients
suffering for CAD.All individual have been investigated with the original
method of "Myocardial Ischaemic Preconditioning", described elsewhere (1).
Unavoidable is the auscultatory percussion of the stomach: in healthy
individuals, digital pressure of mean intensity, applied upon heart
cutaneous projection area, brings about the so-called gastric aspecific
reflex (= in the stomach, fundus and body are dilated; on the contrary,
antral-pyloric region contracts) after a latency time of 7- 8 sec., age-
dependent.
A second, successive evaluation, performed exactly after an interval of 5
sec., provokes the identical reflex, but after lt. of 10 sec.:
physiological myocardial preconditioning.
On the contrary, in all patients involved by risk of CAD (300), latency
time persists identical. On the contrary, in all cases of CAD, even
silent, (250) lt. becomes clearly shorter than that of the pathological
basal value, in relation with CAD seriousness. Diagnosis was subsequently
corroborated with sophysticated semeiotics.
Such as clinical method, easy and rapid to perform, proved to be really
usefull in bed-side recognizing the real risk of Cad (impairement of
microcirculatory functional reserve (MFR) of coronary capillary bed, as
well as heart ischemic disease, even asymptomatic.
Biophysical Semeiotics allows doctors to recognize clinically patients
involved by both risk of CAD, and CAD, even silent, years or decades
before disorder onset.
1) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos,
Preconditioning and Myocardial Oxygenation evaluated clinically with the
aid of Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease
even silent. Acta Med. Medit. 13, 109, 1997
Competing interests:
None declared
Competing interests: No competing interests
I fear I am missing something.
To me this paper suggests that between 1985 and 1999 that workers
with diagnosed and presumably treated angina fared no better than
colleagues whose angina remained undiagnosed.
I think we should fall back on the "two different groups" argument.
Competing interests:
None declared
Competing interests: No competing interests
Prognosis – which is more decisive: angina or abnormal results on electrocardiogram
Sir,
Colleagues Hemingway et al. write about undiagnosed angina and its
prognosis. Abnormal results in resting electrocardiogram had a clear
impact on angina patients’ prognosis (non-fatal myocardial infarction and
all cause mortality) regardless of whether their angina had been diagnosed
or not. The authors state that “… we investigated each participant with a
resting 12 lead electrocardiogram at phases 1, 3, and 5”. Do I interpret
this correctly when I assume that electrocardiogram was recorded on all
participants, even those without angina? If so, what was the prognosis of
participants with abnormal electrocardiogram but no angina?
From the all type mortality table (Table 2) one can see that
mortality of angina patients without abnormal test results was not higher
than that of participants with no angina or myocardial infarction. Authors
do not state how high was the risk of non-fatal myocardial infarction of
angina patients without abnormality on electrocardiogram. Thus the poorer
prognosis seems to be connected to abnormality on electrocardiogram, not
angina as such. If we use angina questionnaire as a screening tool and
only when positive investigate with electrocardiogram, we miss the cases
with abnormal electrocardiogram but no angina. This is probably acceptable
and practical but if electrocardiogram was indeed carried out on all
participants (also those without angina) the authors might be able to shed
light on the amount of such persons and their prognosis in this kind of
setting.
Yours sincerely
Juhani Jääskeläinen
GP, Tampere, Finland
Competing interests:
None declared
Competing interests: No competing interests