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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59:M161-M165 (2004)
© 2004 The Gerontological Society of America

Prevalence and Risk Factors for Angina in Elderly Taiwanese

Yu-Cheng Lin1, Fang-Yeh Chu1, Cheng-Chung Fu2 and Jong-Dar Chen1

1 Department of Family Medicine, Tao-Yuan General Hospital, Taiwan, Republic of China.
2 Department of Internal Medicine, Tzu Chi General Hospital, Taiwan, Republic of China.


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Angina is a hallmark symptom of cardiovascular disease, which has become an important public health issue in Taiwan. The purpose of this study was to examine the prevalence of angina and its risk factors in elderly Taiwanese.

Methods. The study was based on a government-sponsored health examination performed in Tao-Yuan, North Taiwan, from April to June 2001. A total of 2060 participants aged 65 years and older were enrolled. Data were collected through a physician-conducted Rose questionnaire, a biochemical blood test, and a physical examination. Multivariate logistic regression was used to evaluate the relationship between angina and risk factors.

Results. Prevalence of angina was 15.0% in this study, 15.1% in men, and 14.4% in women. Women had a significantly higher body mass index (BMI), total serum cholesterol, and triglyceride. Participants with hypertension had a 1.6-fold 95% confidence interval (CI): 1.2–2.0 increased risk of having angina, 1.4-fold (95% CI: 1.0–1.9) increased risk for men and 2.1-fold (95% CI: 1.3–3.5) for women. Diabetes mellitus was associated with a 1.8-fold (95% CI: 1.2–2.6) increase in the risk for men. Conventional cardiovascular risk factors such as BMI, cholesterol, triglyceride, and smoking were not significantly associated with angina.

Conclusions. The findings of this study suggest the need to prioritize hypertension treatment for elderly Taiwanese in both genders, and to provide adequate diabetes mellitus treatment for men, as these conditions are associated with the development of angina, a clinical indicator of cardiovascular disease.

EVALUATION of angina pectoris is important in epidemiological survey and clinical practice of cardiovascular disease, but sometimes ignored by both patients and doctors (1,2). Vigilance for and investigation of chest pain is a valuable means by which the incidence and progression of cardiovascular disease can be reduced in the primary care setting.

In previous large-scale studies, chest pain postcard questionnaires, telephone calls, and trained medical student interviews (3–5) have been used and taken to be an acceptable tool for chest pain as well as cardiovascular disease evaluation (5–7). Naturally, a structured questionnaire conducted by a trained physician has the potential to better identify and differentiate the characteristics of chest pain.

We conducted a government-sponsored periodic health examination for people aged older than 65 years in North Taiwan to determine the prevalence of angina and its risk factors. A physician-conducted Rose chest pain questionnaire was used to evaluate symptoms of angina.


   METHODS
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Participants
Between April 2001 and June 2001, a total of 2248 elderly people received a periodic health examination in the Tao-Yuan general hospital. The health examination was sponsored by the county government and was offered to all Tao-Yuan County residents over 65 years of age.

Health Examination and Rose Questionnaire
The health examination included a questionnaire regarding personal medical history, a biochemical blood test, and a comprehensive physical examination. The traditional Chinese-translated version of the Rose Questionnaire was used to evaluate angina. All Rose Questionnaire interviews were conducted in the clinics by trained physicians during the health examination.

The Rose Questionnaire questions were as follows:

Definition of Rose Angina
The results of the Rose Questionnaire were reviewed by a cardiologist. The definition of Rose angina was the same as in a previously reported study (2) and is as follows:

Rose angina.-- Definite angina: Participants were regarded as having definite angina if they answered yes to (a) "Do you ever have any pain or discomfort in your chest?" and (b) "When you walk uphill or hurry, does this produce pain?" Four additional criteria also had to be satisfied: (i) the distribution of pain included a specific location on the chest; (ii) the participant slowed down or stopped walking when the pain occurred; (iii) the pain went away if the participant stood still; and (iv) did so in less than 10 minutes.

Rose angina.-- Possible angina: Chest pain was present on exertion but did not fulfill all four of the additional criteria.

Definite or possible angina was considered to be Rose angina (8).

Statistical Analysis
The Student's t test was used for analysis of continuous variables, and the chi-square test was used for categorical variables. Multivariate logistic regression was used to evaluate the relationship between angina and risk factors. Statistical analysis was performed using SAS software version 8.0 (SAS Institute, Cary, NC).


   RESULTS
Top
 Abstract
 Methods
 Results
Discussion
 References
 
A total of 188 participants were excluded due to incomplete data (i.e., biochemical blood tests, questionnaires). This left a total of 2060 participants in the final analysis.

As shown in Table 1, the overall prevalence of angina was 15%, with a prevalence of 15.1% for men and 14.4% for women. Elderly women had a significantly higher mean value of body mass index (BMI), total serum cholesterol, and triglyceride. Elderly men had a higher prevalence of hypertension and higher prevalence of alcohol use and smoking than women.


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  		Table 1. Baseline Characteristics of Elderly Taiwanese Who Underwent Periodic Health Examination in North Taiwan.

 
The distribution of risk factors among elderly people with and without angina is shown in Table 2. Elderly men who had angina had higher mean values of BMI and fasting serum glucose levels than those who did not. The prevalence of hypertension and diabetes was significantly higher among elderly men with angina when compared to those without. Women with angina had a higher mean value of BMI and prevalence of hypertension; however, there was no significant difference in the serum level of fasting serum glucose and prevalence of diabetes between elderly women with and without angina. Age and lipid profiles were not obviously related to angina in either men or women.


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  		Table 2. Distribution on Risk Factors Among Elderly Taiwanese With and Without Angina.

 
The results of multiple logistic regression are shown in Table 3. Elderly people with hypertension had a 1.6-fold (95% confidence interval (CI): 1.2–2.0) increase in the risk of having angina, the odds ratio was 1.4-fold (95% CI: 1.0–1.9) for men and 2.1-fold (95% CI: 1.3–3.5) for women. Elderly men with diabetes mellitus had a 1.8-fold (95% CI: 1.2–2.6) increased odds of having angina, but the effect of diabetes mellitus was not significant among women. Among the entire group, those with a higher BMI had a higher risk of having angina, but this risk was not apparent when participants were separated into male and female groups. The odds ratios for having angina are summarized in Figure 1.


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  		Table 3. Multivariate Logistic Regression of the Effect of Risk Factors on the Occurrence of Angina.

 


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  		Figure 1. The odds ratio (OR) of risk factors for developing angina, analyzed using logistic regression. BMI = body mass index

 

   DISCUSSION
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Angina was found to be significantly associated with hypertension, diabetes, and abnormally high values of BMI, while total serum cholesterol and triglyceride showed no significant association with angina in this study. After dividing into gender subgroups, risk factors associated with angina were hypertension in both genders and diabetes in elderly men.

Elderly people with hypertension in this study had an increased risk of having angina, with odds of 1.4 for men and 2.1 for women. These findings were similar to those of previous studies of cardiovascular disease (8,9); however, hypertension seemed to be a particularly important risk factor for angina in elderly Taiwanese women as it was the only risk factor for angina shown to be of significance on logistic regression analysis.

Previous studies have established that diabetes mellitus is a risk factor for cardiovascular disease in elderly people (9,10), The Systolic Hypertension in the Elderly Program study found that diabetes mellitus was associated with an approximately 2-fold increase in cardiovascular disease in elderly patients (11). In this study, diabetes mellitus was associated with an approximately 1.8-fold increase in angina among elderly men, but no significant association was found among elderly women, these findings are similar to previous studies of angina (12,13) and cardiovascular disease (12–15). Such a gender difference was demonstrated in previous studies (11,12,14). Lempiainen and colleagues suggested that insulin resistance, one of the key factors responsible for hyperglycemia in type 2 diabetes that can also result in a number of metabolic abnormalities, was predictive of cardiovascular events in men but not in women (14,15). The findings of this study support the notion that diabetes mellitus is an independent risk factor for angina in elderly people, but is not as important for women as it is for men.

In previous studies of Western populations, blood lipids were found to be a very important risk factor (9,16,17), and overweight (9,18,19) was usually found to be a significant risk for cardiovascular disease. In this study, serum cholesterol and triglyceride were not significantly associated with angina, and the effect of BMI on angina was not found to be significant in either men or women. There are several possible explanations for these findings. Past studies of Asian populations (20) have usually found lower body weight and a favorable blood lipid profile when compared to studies based on Western populations. Genetic differences (21) and differences in diet components (22) may have affected these findings. In addition, although angina is a hallmark symptom of cardiovascular disease, some noncardiogenic chest pain might mimic angina (23). The use of different definitions of outcome measurement (angina vs cardiovascular disease) may also partially explain the differences in findings of risk factors.

Smoking is an established risk factor for cardiovascular disease (9), but the definite association of smoking and angina remains controversial (24,25). In our study, the association between smoking and angina was insignificant. Because the information of smoking was collected by binary criteria in this study, the impacting effect of smoking on angina might be underestimated (26).

Summary
The prevalence of angina among the elderly Taiwanese population is around 15%. Hypertension was found to be the most important risk factor for angina in elderly women. Diabetes mellitus and hypertension were two significant risk factors for elderly men. Risk factors for cardiovascular disease such as body weight and blood lipids were found to be of less importance for elderly Taiwanese to develop angina. The findings of this study suggest the need to prioritize hypertension treatment for elderly Taiwanese of both genders, and to provide adequate diabetes mellitus treatment for men, as these conditions are associated with the development of angina, a clinical indicator of cardiovascular disease.


   Acknowledgments
 
The authors would like to acknowledge the support of Tao-Yuan County Government. We thank the personnel of the Department of Family Medicine, Tao-Yuan General Hospital, Tao-Yuan, Taiwan for their full support and help.

Address correspondence to Jong-Dar Chen, MD, Department of Family Medicine, Tao-Yuan General Hospital, 1492, Jaung-Shan Road, Tao-Yuan, Taiwan, R.O.C. 330. E-mail: jdarchen{at}ms28.hinet.net

Received December 9, 2002

Accepted January 27, 2003


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

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