Original Title: Effect of the presence and type of angina on cardiovascular events in patients without known coronary artery disease referred for elective coronary angiography. Reference: Vavalle JP et al. JAMA Cardiology 2016; Epub ahead of print.

Patients presenting typical angina with a negative stress test result prior catheterization have a high rate of heart disease, according to a recent analysis of patients undergoing elective coronary angiography.

Different was the case of those with atypical symptoms with positive stress test results, where only one every four patients had obstructive coronary artery disease.

These results show the importance of clinical judgement and intuition when examining patients with a possible heart disease.

The study included 15888 patients with no known history of coronary artery disease receiving elective coronary angiography between 1996 and 2010 at Duke University Medical Center.

36.9% of patients presented typical angina, 38.8% atypical symptoms and 24.3% were completely asymptomatic.
A total 4994 patients had had a pre-catheterization stress test: 3812 resulted negative and 1182 resulted positive for ischemia indicators.

Something worth noticing is that more than two thirds of patients were referred directly to coronary angiography with no prior functional test. The reason behind this was coronary artery disease was highly suspected and no intermediate test could have made a difference.

In the present analysis, patients with typical angina showed the highest rate of coronary disease. 74.3% of patients with typical symptoms but with negative stress test results showed significant coronary artery disease by coronary angiography.

In those with typical symptoms that were not tested and went directly to a coronary angiography, nearly 70% coronary artery disease was observed.

The lowest rate of obstructive coronary artery disease (24.6%) was observed in those with typical symptoms and positive stress test results.

In the era of modern diagnostic studies, there is still room for clinical judgement at the patient’s bedside.