Editorial

Angina, myocardial ischemia and coronary disease: Gold standards, operational definitions and correlations

Angina pectoris (AP) as determined by the Rose questionnaire was assessed in nearly 16,000 black and white men and women participating in the Atherosclerosis Risk in Communities Study, a population study of cardiovascular disease in four communities. The questionnaire was administered at yearly intervals and estimates of repeatability were made. Validity was assessed indirectly by comparing Rose AP to risk factors, prevalent heart disease, medication use, and thickness of carotid artery walls as measured by B-mode ultrasound. Using κ statistics for agreement of positive Rose AP determinations taken 1 year apart, white men show a higher level of agreement than white women (average κ 0.36 for white men, 0.30 for white women), and whites show a higher level of agreement than blacks (average κ 0.23 and 0.22 for black men and women, respectively). Rose AP that persists for more than one determination is associated with thicker carotid artery walls, greater amounts of cigarette smoking, greater prevalence of reported heart attack, and greater use of chest pain medications. A single determination of severe Rose AP is also associated with thicker carotid artery walls. These data suggest that multiple reports and the more severe grading of Rose AP (pain reported while walking on the level) are likely to indicate more severe disease; however, a single report using the Rose questionnaire appears valid, i.e., moderately associated with disease and risk factors, and appropriate for use in epidemiological studies.

Validation of the London School of Hygiene (Rose) Questionnaire with objective measures of myocardial ischemia is incomplete. Therefore, we compared the Rose Questionnaire with exercise thallium-201 myocardial scintigraphy in 147 male and 97 female patients with chest pain referred for clinical exercise testing. Of those with “Rose Questionnaire angina”, 26% of the females and 73% of the males had positive thallium-201 scans. Negative results on both the Rose Questionnaire and thallium-201 scintigraphy were observed in 71 % of the females and 47% of the males. The sensitivity of the Rose Questionnaire was similar in females (41 %) and males (44%). The specificity was 77% in males, while in females it was significantly lower at 56%. The specificity values reflect the higher (p < 0.05) prevalence of “false positive” Rose Questionnaire results in females (75%) compared with males (27%). In addition, males had a greater (p < 0.05) number of “false negative” results (53%) than females (29%). The accuracy of the Rose Questionnaire for myocardial ischemia was 0.19 in females, 0.48 in males, and 0.29 overall when including both males and females.

Our results indicate a generally poor relationship between Rose Questionnaire angina and thallium-201 scintigraphy, an objective measure of myocardial ischemia in patients with chest pain referred to clinical exercise testing. Further, there are gender-specific differences in this relationship between the questionnaire and exercise thallium-201 imaging.