Original articles
Rose Questionnaire Angina in Younger Men and Women: Gender Differences in the Relationship to Cardiovascular Risk Factors and Other Reported Symptoms

https://doi.org/10.1016/S0895-4356(99)00007-4Get rights and content

Abstract

Cross-sectional data from the Whitehall II study baseline were used to identify factors that may lead to the high levels of Rose angina reporting in women. 134 (4.0%) of 3350 women and 164 (2.4%) of 6830 men reported angina (P < 0.001). Women with Rose angina had a poorer cardiovascular risk profile (degree of obesity, serum cholesterol and apolipoprotein B, blood pressure) and more electrocardiogram abnormalities (ST and T changes) than women without angina, but the associations were generally weaker than in men. Women who reported many other physical symptoms had a high prevalence of Rose angina (9.7%). Adjustment for symptom reporting reduced the age-adjusted gender difference to odds ratio (OR) = 0.93 (95% confidence interval [CI]: 0.56–1.56) for subjects with no symptoms, and to OR = 1.42 (95% CI = 1.05–1.90) for subjects at the upper quartile of symptom score. Among women a high level of general symptom reporting was associated with General Health Questionnaire (GHQ) minor psychiatric morbidity (51.9% prevalence), but GHQ caseness does not appear to be a predictor of Rose angina (OR 1.22 [0.67–2.21]) in this group. Coronary artery disease risk is raised in women with Rose angina, and this remains true in groups with high levels of general symptom reporting.

Introduction

Coronary artery disease (CAD) mortality and morbidity from myocardial infarction is less common in women than in men at all ages, with the gender differential greatest in people younger than 55 years of age 1, 2. Although fewer data are available for women than for men, the predictors of major CAD events appear to be the same 3, 4, suggesting that CAD in women is not a fundamentally different disease from that in men. The pathophysiology of chest pain and its relationship to angina pectoris in women remain a subject of controversy and confusion. Many reports 5, 6, 7 have shown that chest pain is more common in women than men and prevalence is higher than the levels of other CAD events would suggest. The prognosis of women with chest pain is worse than that of women without such pain [8] but better than that of men with chest pain, with lower rates of myocardial infarct and CAD death in women subsequent to a clinical diagnosis of angina 9, 10, 11. However, the apparent survival advantage for women is diminished if subgroups of women with either more frequent or classical symptoms are identified 8, 9. Other work [12] clearly demonstrates that the prevalence of stenosing CAD in women undergoing coronary angiography for chest pain is lower than in men. Such data may have given rise to the perception that chest pain is less serious in women [13] and even to discrimination against women with CAD in the form of lower rates of referral for investigation and revascularization 14, 15. The literature suggests that among women with chest pain, a proportion have coronary heart disease, but that proportion is smaller than among men with chest pain. This may be described as a dilution effect. The challenge clinically is therefore to identify those women with CAD within the larger group with chest pain syndromes [16]. There are implications also for epidemiology that uses angina as a measure of prevalence of CAD in a population.

The most widely used instrument to measure angina in populations is the Rose questionnaire, which has been validated in men against physician diagnosis and electrocardiogram (ECG) abnormality and as a predictor of CAD mortality 17, 18. The performance of the questionnaire against measures of myocardial ischemia such as thallium scanning 19, 20 has been less favorable, and specificity is lower in women than men (56% versus 77%) [20]. In recent years, there has been growing criticism of the questionnaire, particularly in relation to its use in women. This article studies correlates of Rose angina in younger men and women (aged 35–55 years) in order to address two objectives: first, to examine evidence for dilution of the relationship between Rose angina and CAD in women as assessed by cardiovascular risk factors and ischemia on ECG, and second, to investigate whether other physical and mental symptoms may influence Rose angina reporting and thus contribute to the increased prevalence in women.

Section snippets

The Study Population

Cross-sectional data from the Whitehall II study [21] were used in the analyses. This cohort study of government employees was set up to investigate the contribution of psychosocial factors, including work stress, to health inequalities. The baseline (phase 1) screening examination was performed between 1985 and 1988. Staff aged 35–55 years from 20 civil service departments based in London were invited to attend. The response rate was 73%, with 6895 (74%) men and 3413 (71%) women participating.

Prevalence of Angina

As expected, there was a female excess of angina, with crude prevalences of 4.0% (134/3350) of women and 2.4% (164/6830) of men reporting angina (χ2 = 20.22 on 1 df, P < 0.001). The prevalence of angina increased linearly over the age range 35–55 years in men, with a prevalence of 1.8% in men aged 35–39 years, 2.1% in those aged 40–44 years, 2.9% in those aged 45–49 years, and 3.1% in those aged 50–55 years (trend, P = 0.004). The equivalent figures for women were 3.3%, 4.2%, 3.6%, and 4.6%

Relationship of Rose Angina to Electrocardiogram Abnormality and Cardiovascular Risk Factors

The first objective of the analyses was to compare the relationship of risk factors and markers for CAD with angina in men and women. The suggested dilution effect (of angina related to CAD by angina unrelated to CAD) would lead to weaker associations in women. Men with angina have a substantially higher prevalence of ECG abnormalities suggestive of ischemia than men without angina. The differences in women are less marked, although there is an association with ST depression. Likewise, men with

Conclusion

This study has demonstrated that among younger men and (mainly premenopausal) women, associations between Rose angina and cardiovascular risk factors and ECG abnormalities are weaker in women, consistent with a dilution effect, and with a larger proportion of Rose angina unrelated to CAD than in men. The relationship between increased symptom reporting and angina is stronger in women than men, and much of the increased Rose angina reporting in women appears to be accounted for by those

Acknowledgements

We thank all participating civil service departments and their welfare, personnel, and establishment officers; the Occupational Health and Safety Agency; the Council of Civil Service Unions and all participating civil servants. We thank all members of the Whitehall II study team and, in particular, Robert Canner for computer support, and screening coordinator Julie Moore. The work presented in this article was supported by grants from the Medical Research Council; Health and Safety Executive;

References (39)

  • Coronary heart disease incidence, by sex: United States 1971–1987. MMWR 1992; 41:...
  • T. Wilcosky et al.

    The prevalence and correlates of Rose questionnaire angina among women and men in the Lipid Research Clinics program prevalence study

    Am J Epidemiol

    (1987)
  • A.Z. Lacroix et al.

    Rose questionnaire angina among United States black, white, and Mexican-American women and men

    Am J Epidemiol

    (1989)
  • V. Krogh et al.

    Prevalence and correlates of angina pectoris in the Italian nine communities study

    Epidemiology

    (1991)
  • E. Weinblatt et al.

    Prognosis of women with newly diagnosed coronary heart disease—a comparison with course of disease among men

    Am J Public Health

    (1973)
  • J.M. Murabito et al.

    Prognosis after the onset of coronary heart diseaseAn investigation of differences in outcome between the sexes according to initial coronary disease presentation

    Circulation

    (1993)
  • B.R. Chaitman et al.

    Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS)

    Circulation

    (1981)
  • N.K. Wenger

    Gender, coronary disease, and coronary bypass surgery

    Ann Intern Med

    (1990)
  • J.Z. Ayanian et al.

    Differences in the use of procedures between women and men hospitalized for coronary heart disease

    N Engl J Med

    (1991)
  • Cited by (28)

    • Angina symptoms in men and women with stable coronary artery disease and evidence of exercise-induced myocardial perfusion defects

      2006, American Heart Journal
      Citation Excerpt :

      Typical angina is defined as chest pain or discomfort that is (1) precipitated by effort, (2) located retrosternally, and (3) promptly relieved by rest or nitroglycerin. Atypical angina meets 2 of 3 criteria, whereas nonspecific chest pain meets 1 or none of these criteria.35,36 The Canadian Cardiovascular Society grading scale of angina pectoris37 classifies the degree to which a patient's functional capacity is limited as a result of angina symptoms.

    • The menopausal transition was associated in a prospective study with decreased health functioning in women who report menopausal symptoms

      2005, Journal of Clinical Epidemiology
      Citation Excerpt :

      The three hypotheses examined are that (a) health functioning changes for women as they progress through the menopausal transition, (b) menopausal symptom reporting is related to the decline in health functioning, and (c) a group of women are vulnerable to a more symptomatic menopausal experience and more likely to report menopausal symptoms. Demographic and psychosocial characteristics, health and risk factor status of the 10,308 participants (3,413 women) at baseline have been described previously [25,26]. Participants were recruited in 1985–1988 (phase 1) from 20 London-based civil service departments.

    • Novel risk factors related to stable angina

      2013, Current Pharmaceutical Design
    View all citing articles on Scopus

    Ian White is currently at the Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, UK.

    View full text