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Predicting death from coronary heart disease using a questionnaire
C J Bulpitt1, M J Shipley, J Demirovic
1London School of Hygiene and Tropical Medicine, UK.
Insights
A questionnaire screening tool effectively predicts coronary heart disease (CHD) mortality in men. Combining 11 questions, including chest pain and dyspnea, offers the best balance of specificity and sensitivity for population studies.
Area of Science:
- Cardiovascular epidemiology
- Public health screening
Background:
- Coronary heart disease (CHD) remains a leading cause of mortality.
- Effective screening tools are crucial for population health management.
- The Whitehall study provides a valuable dataset for epidemiological research.
Purpose of the Study:
- To evaluate the predictive power of a questionnaire for ten-year CHD mortality.
- To assess the utility of self-reported symptoms as a screening tool for CHD risk.
- To identify optimal combinations of questions for population-based screening.
Main Methods:
- Analysis of questionnaire responses from 18,322 male civil servants (aged 40-64).
- Examination of ten-year CHD mortality data (1714 deaths, 723 from CHD).
- Evaluation of different algorithms based on reported symptoms (angina, chest pain, dyspnea, diabetes, physician visits).
Main Results:
- Angina plus possible myocardial infarction (PMI) yielded 99% specificity but only 7% sensitivity.
- Angina and/or PMI improved sensitivity to 29% with 90% specificity.
- An 11-question algorithm including dyspnea, diabetes, and physician visits achieved 85% specificity and 44% sensitivity.
- Excluding 'yes-set' responders slightly increased specificity but reduced sensitivity.
Conclusions:
- A multi-symptom questionnaire, particularly an 11-question combination, is recommended for CHD screening.
- This screening approach balances high specificity with improved sensitivity for identifying at-risk individuals.
- Further refinement of screening questions may enhance predictive accuracy for coronary heart disease mortality.
Abstract:
The ten-year coronary heart disease (CHD) mortality is reported for 18,322 male civil servants aged 40 to 64 according to questionnaire responses at entry into the Whitehall study. In all 1714 died, 723 from CHD. The predictive power of the questionnaire was examined with a view to its use as a screening tool in population studies. In predicting death from coronary heart disease the greatest specificity (true negative rate) was achieved with men reporting both angina (A) and a history of severe chest pain (possible myocardial infarction, PMI). This strategy (A plus PMI) achieved a specificity of 99% but a sensitivity (true positive rate) of only 7%. In contrast, in men reporting angina and/or PMI, specificity was 90% and sensitivity 29%. If this 'and/or' algorithm was extended to include the report of dyspnoea, diabetes, and/or attending a primary care physician with heart disease or hypertension, then specificity was still 85%, but sensitivity increased to 44%. This combination (11 questions in all) is therefore recommended for screening purposes. Identifying and excluding those who favour positive answers ('yes-set' responders), using questions such as the effect of weather on breathing, led to small increases in specificity but relatively large falls in sensitivity. Among subjects reporting chest pain, those who also complained of non-specific symptoms experienced only half the mortality of those with none of these additional complaints.