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Raising a red flag about angina – an under-recognised and under-treated disorder

Johannesburg, 3 September 2020: The burden of cardiovascular disease continues to grow in South Africa.1 The age-standardised death rates for non-communicable diseases (NCDs) in South Africa are now higher than those of HIV/AIDS and tuberculosis combined,2 with cardiovascular disease being the leading category of NCDs.2 Ischaemic heart disease (IHD) is a major contributor to cardiovascular disease in this country, and the most common symptom of IHD is angina pectoris.3 As part of stemming this tide, it is therefore vital that cases of angina are picked up and treated.

“A sad fact is that many doctors are not picking up that their patients have angina,” says Dr Tawanda Butau, chair of the education committee of the South African Heart Association. “A large number of angina patients remain undiagnosed and, as a result, are under-treated. We need doctors to know that angina is a real – and common – problem, and to understand the important role they play in diagnosing their patients and providing optimal treatment. Doctors, therefore, need to be asking their patients the right questions during consultations to uncover hidden cases of angina.”

Complicating this matter is the fact that only 2.7% of angina patients spontaneously describe their symptoms in detail.4 Among patients who are experiencing monthly angina, up to 25%  do not discuss it with their cardiologist.5 It is hardly surprising then that 43% of patients who have experienced angina in the past month remain under-recognised as having the condition.6

The phenomenon of patients not disclosing to their doctor is hardly new, and it has a gendered aspect. Women often rationalise warning signs of physical problems.7 Indeed, a Yale cardiology study7 found that many women hesitated to seek help for a heart attack because they worried about being thought of as hypochondriacs. In addition, women tend to delay longer in seeking care than men.7

Likewise, for years angina was thought to be more prevalent in males, but a study conducted by the University College London Medical School found the incidence of stable angina to be slightly higher in women than men.8

It is for this reason that the Angina Awareness Initiative, together with the South African Heart Association and the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy, seeks to raise a red flag around angina. Says Dr David Jankelow, president of the South African Heart Association: “The wider medical community needs to be acutely aware that cardiovascular disease (CVD) is the biggest killer in the world; with almost 40 000 deaths per day as a result, and up to 300 every day in South Africa. Therefore, primary care doctors need to take the initiative with a careful history to detect suggestive symptoms of CVD and possible angina.”

Angina symptoms may include chest discomfort, fatigue, breathing difficulties, arm pain, nausea and neck pain.9 The Yale study7 found that even though the vast majority of patients presented with the hallmark symptom of chest pain, women were less likely to experience chest pain and more likely to present with other symptoms, such as pain or discomfort in the back, jaw, or throat as well as headache, nausea, and coughing.

Doctors also need to be more aware of the options for managing angina. A recent study found that the management of stable angina pectoris in private healthcare settings in South Africa is skewed towards surgical interventions, as opposed to optimal medical therapy (OMT).10  This is contrary to what consistent scientific evidence and international treatment guidelines suggest.10 Only 25% of patients who might have benefitted (average age 65 years) were treated with OMT as the initial management approach.10 In a rural South African population, only 6% of those with angina were receiving treatment at all.11

The Angina Awareness Initiative is a worldwide endeavour aimed at increasing awareness about angina and its risk factors among patients and healthcare providers to improve its management. 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 Angina Awareness Initiative is supported by an unrestricted grant from Servier.



1 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.

2 Nojilana B, Bradshaw D, Pillay-van Wyk V, et al. Persistent burden from non-communicable diseases in South Africa needs strong action. SAMJ.2016;106:436-437.

3 Balla C, Pavasini R, Ferrari R. Treatment of angina: where are we? Cardiology. 2018;140:52-67.

4 Berliner D, Maier LS, Wollenburg U, et al. Clinical care for patients with recurrent myocardial ischemia in Germany—the VOICES trial. J Thorac Dis. 2018;10(suppl 15):S1777-S1784.

5 Alexander KP, Stadnyuk O, Arnold SV, et al. Assessing quality of life and medical care in chronic angina: An internet survey. Interact J Med Res. 2016;5(2):e12.

6 Qintar M, Spertus JA, Gosch KL, et al. Effect of angina under-recognition on treatment in outpatients with stable ischaemic heart disease. Eur Heart J Qual Care Clin Outcomes. 2016;2(3):208-214.

7 Lichtman JH, Leifheit-Limson EC, Watanabe E, et al. Symptom recognition and healthcare experiences of young women with acute myocardial infarction. Cardiovasc Qual Outcomes. 2015;8:S31-S38.

8 Hemingway H, Langenberg C, Damant J, et al. Prevalence of angina in women versus men. Circulation. 2008;117(12):1526-1536.

9 Mayo Clinic [Internet]. Angina. Symptoms. Mayo Clinic. c2020. Available from: https://www.mayoclinic.org/diseases-conditions/angina/symptoms-causes/syc-20369373.

10 Tlhakudi P, Mathibe LJ. Management of stable angina pectoris in private healthcare settings in South Africa. Cardiovasc J SA. 2018;29:237-240.

11 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.