Angina is common, but frequently missed and undertreated
The cardiovascular disease (CVD) burden in South Africa is increasing among all age groups and is predicted to become the principle contributor to overall morbidity and mortality in people over the age of 50.1 p48a Ischaemic heart disease (IHD) is a major contributor to CVD in this country. It is one of the 10 leading causes of death overall and, in 2016, was the 5th leading cause of death in people older than 65 years.2 p33, 37 In the 2014 South African National Health and Nutrition Examination Survey (NHANES), the prevalence of heart attack, angina and chest pain (IHD) was approximately 6% among Africans, 14% among Whites and 29% among individuals of Asian or Indian descent.3 p73
IHD is responsible for considerable morbidity worldwide and the most common symptom of it is angina pectoris.4 p1a International data suggests around half of all people with coronary artery disease (CAD) initially present with angina, and of those reporting angina, approximately one out of four report daily or weekly symptoms.5,6 5.p1a, 6. p423a Patients with angina are more than twice as likely to suffer a major cardiovascular event and frequently live with anxiety and depression.5,7 5.p1a; 7.p4a Angina interferes with ability to perform daily activities, impairs quality of life and may necessitate early retirement because of inability to continue working.4 p4c
In South Africa, too, angina is common in people with cardiovascular disease (CVD). In a rural population of adults in Mpumalanga with a mean age of 62 years, the overall prevalence of angina was approximately 9%. In total, 77% of the individuals who said they had CVD (12% of the total population) reported having angina.8 p4a,b; p5c, p3d
The Heart of Soweto study examined the prevalence of heart disease in a large urban South African community undergoing epidemiological transition. Among more than 5000 individuals presenting to the cardiology unit at the Chris Hani Baragwaneth Hospital in Soweto, Gauteng, the prevalence of angina was 12% overall, 11% among the African patients and 17% among a group of Caucasian, Indian and mixed descent individuals.9 p495a, p493b
In 2016, The Heart and Stroke Foundation of South Africa estimates that every hour five people in South Africa will have a heart attack.10
Despite the high prevalence of angina, globally, it remains under-recognised and suboptimally managed, both in terms of advice regarding lifestyle modification and appropriate use of medication and/or coronary revascularisation.4 p1b In one study of patients in cardiology outpatient practices in the USA, angina was under-recognised in 43% of patients who reported symptoms in the previous month.11 p1a Among patients with frequent angina, 44% were on suboptimal antianginal pharmacotherapy.12 p1a
Optimal medical therapy (OMT) is pivotal in the management of stable angina pectoris. Studies show that there are no differences between percutaneous interventions and OMT with regard to all major outcomes and current clinical guidelines recommend OMT to control symptoms before considering coronary artery revascularisation.4,13 4. p1c; 13. p3a However, even in the private cardiology service in SA, only 25% of patients who might have benefitted (average age 65 years) were treated with OMT as the initial management approach.13 p3b In a rural South African population only 6% of those with angina were receiving treatment at all.8 p4b
In response to these alarming international figures, the European Society of Cardiology (ESC) Working Group on Cardiovascular Pharmacotherapy has launched the Angina Awareness Initiative. This is a worldwide initiative aimed at increasing awareness on angina and its risk factors among patients and healthcare providers to improve its management.14 In South Africa, the scientific partner is the South African Heart Association, whose vision is to advance cardiovascular healthcare for all living in South Africa.
The first Angina Awareness week took place in April 2019. For more information visit https://angina-awareness-initiative.com. This initiative was supported by an unrestricted grant from Servier.
- Maredza M, Hofman KJ, Tollman SM. A hidden menace: cardiovascular disease in South Africa and the costs of an inadequate policy response. SAHeart 2011; 8: 48-57.
- Statistics South Africa. Mortality and causes of death in South Africa, 2016: Findings from death notification. February 2019. Available from http://www.stassa.gov.za. Accessed 9 April 2019.
- Shisana O, Labadarios D, Rehle T, et al, for the SANHANES-1 Team (2014) South African National Health and Nutrition Examination Survey (SANHANES-1): 2014 Edition. Cape Town: HSRC Press.
- Balla C, Pavasini R, Ferrari R. Treatment of angina: where are we? Cardiology 2018; 140: 52-67.
- Ohman EM. Chronic stable angina. N Engl J Med 2016; 374: 1167-1176.
- Benjamin EJ, Muntner P, Alonso A, et al, on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics – 2019 Update. A Report From the American Heart Association. Circulation 2019; 139: e56-e528.
- Ketterer MW, Bekkouche NS, Goldberg AD, et al. Symptoms of anxiety and depression are correlates of angina pectoris by recent history and an ischemia-positive treadmill test in patients with documented coronary artery disease in the Pimi Study. Cardiovasc Psych Neurol 2011: 134040. DOI: 10.1155/2011/134040
- Jardim TV, Reiger S, Abrams-Gessel S, et al. Disparities in management of cardiovascular disease in rural South Africa. Data from the HAALSI Study (Health and Aging in Africa: Longitudinal Studies of International Network for the Demographic Evaluation of Populations and Their Health Communities). Circ Cardiovasc Qual Outcomes 2017; 10: e004094. DOI: 10.1161/CIRCOUTCOMES.117.004094.
- Stewart S, Carrington M, Pretorius S, et al. Standing at the crossroads between new and historically prevalent heart disease: effects of migration and socio-economic factors in the Heart of Soweto cohort study. Eur Heart J 2011; 32: 492-499.
- Heart and Stroke Foundation South Africa. Cardiovascular disease statistics reference document. March 2016. Available at: http://www.heartfoundation.co.za/wp-content/uploads/2017/10/CVD-Stats-Reference-Document-2016-FOR-MEDIA-1.pdf. Accessed 9 April 2019.
- Qintar M, Spertus JA, Gosch KL, et al. Effect of angina under-recognition in treatment in outpatients with stable ischaemic heart disease. Eur Heart J – Qual Care Clin Outcomes 2016; 2(3): 208-214.
- Kureshi F, Shafiq A, Arnold SV, et al. The prevalence and management of angina among patients with chronic coronary artery disease across US outpatient cardiology practices: insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study. Clin Cardiol 2017; 40(1): 6-10.
- Tlhakudi P, Mathibe LJ. Management of stable angina pectoris in private healthcare settings in South Africa. Cardiovasc J Afr 2018. Published online. DOI: 10.5830/CVJA-2018-020.
- Angina Awareness Initiative. http://www.angina-awareness-initiative.com