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Pak J Physiol 2010;6(2)
Yathish TR, Nachal Annamalai*, Vinutha Shankar*
Department of Physiology, Hassan Institute of Medical Sciences, Hassan-Karnataka, India,
*Department of Physiology, Sri Devaraj Urs Medical College, Tamaka, Kolar-563101, Karnataka, India
Background: Various tests like Echocardiogram, Nuclear scan, Electron-beam computed
tomography, Coronary angiography, and magnetic resonance angiography are available for diagnosis
of ischemic heart disease (IHD). But most of these are expensive, invasive and cannot be afforded in
developing countries. An attempt was made to study sensitivity, specificity, and predictive value of
non-invasive technique like questionnaire method and compared with traditional clinical evaluation.
This study compared diagnosis of angina made with the Rose Questionnaire to diagnosis by
physician in type-2 diabetes mellitus and the effect of glycaemic control. Methods: A cross-sectional
study was done from March 2005 to March 2006. Cases were collected from outpatients and
inpatients visiting RL Jalappa hospital and SNR Hospital attached to Sri Devraj Urs Medical College
Kolar, Karnataka, India. Glycosylated haemoglobin levels were estimated. Data on Rose
questionnaire angina and physician diagnosed angina were collected and compared between groups
of well controlled diabetics, poorly controlled diabetics and controls. The 12 lead Electrocardiogram
was used to confirm the diagnosis. Results: The Rose questionnaire had 63.63% sensitivity, 97.5%
specificity, 73% positive predictive value, and 96% negative predictive value. This study also
showed the occurrence of IHD was higher in the poorly controlled diabetics (16.3%) as compared to
well controlled diabetic patients (6%) and controls (5%) which were significant. Conclusions: The
questionnaire diagnosis showed good sensitivity and high specificity as compared with diagnosis by
physicians. The questionnaire method can be frequently used and incorporated in cardiovascular risk
assessment and epidemiologic screening programs.
Keywords: Ischemic heart disease, glycosylated haemoglobin, type-2 diabetes mellitus, Rose angina
prevalent among the people of lower socioeconomic status because of negligence, illiteracy, poverty etc. The Rose Questionnaire (RQ), also called as the London Ischemic heart disease, especially Myocardial Infarction School of Hygiene Cardiovascular Questionnaire, has (MI) has reached enormous proportions striking more been frequently used in epidemiologic research as a and more young subjects especially in patients with standard, unbiased and validated measure1 of the diabetes mellitus. It will result in greatest health hazard prevalence of angina in general population surveys since which mankind has ever faced in coming years unless its introduction in 1962. The RQ has been widely we are able to reverse the trends by concentrated results used in its original, modified forms, and in translation to study the prevalence and natural history of ischemic This study was designed to test the sensitivity and specificity of questionnaire and to assess the relation make population comparisons. There is no agreed ‘gold between glycaemic control (assessed by glycosylated standard’ which can be used to validate RQ measures of detected by Rose Angina Questionnaire) so that the risk factor can be identified earlier, prevented and treated. Thallium scans and coronary angiography. Clearly without such a standard the terms ‘sensitivity’ and MATERIAL AND METHODS
‘specificity’ need to be used with caution. The This study was a case- control study. The study group Questionnaire was found to have 81% sensitivity and comprised of 1200 subjects above 30 years of age 97% specificity when compared to clinical judgment.1–3 having Type-2 diabetes mellitus. The control group comprised of 400 subjects above 30 years of age. Cases metabolic endocrine disease affecting mankind. The were collected from outpatients and inpatients visiting incidence of disease is on a rise not only in developed RL Jalappa Hospital and SNR Hospital attached to Sri countries but also in developing countries. It is Devraj Urs Medical College Kolar, Karnataka, India. characterised by elevated fasting and postprandial blood Subjects with history of hypertension, lung or glucose level and variety of multisystem complications, other cardiac disease, smoking and alcoholism, on any mainly in the blood vessels of eye, kidney, nervous drug affecting lipid levels of plasma were excluded from system and integument. The complications are more the study. All subjects were interviewed by means of a Pak J Physiol 2010;6(2)
structured questionnaire for general demographic aged 41–50 and 3.25% in those aged 51–60 years and details, lifestyle, cardiovascular risk factors, history of myocardial infarction, and symptoms of angina Table-2 shows distribution of IHD in non according to the Rose angina questionnaire after the diabetics. The youngest subject in the control group is clearance from ethical committee. The physicians’ aged 31 years and the oldest aged 69 years. The interviews occupied 15–30 minutes each, as compared prevalence of IHD was 0.5% in 31–40 year age group. with about 3–5 minute for the questionnaire. Those who This increased with age, and was 0.75% among those fulfilled all the Rose criteria were classified as having aged 41–50 and 1.75% in those aged 51–60 years and Rose questionnaire angina (RQA). History was taken in detail and general physical examination was done. Table-3 shows IHD is higher in the poorly controlled diabetics when compared to well-controlled discomfort in the chest when walking uphill or hurrying diabetics and normal healthy controls. It also shows the and fulfilling all of the following criteria: (1) situated in association of glycaemia with macro vascular the sternum or the left anterior chest with or without left circulation (i.e., coronary artery disease). arm; (2) caused the subject to stop or slow down; (3) Among 1,600 subjects, 154 (prevalence 9.6%) went away when the subject stopped or slowed down; had angina pain on exertion and rest and 1446 (90.4%) and (4) was relieved within 10 minutes by rest. Possible had no chest pain. Among 1,200 diabetics, 134 (11.2%) MI was defined as having experienced a severe pain had a classic symptom of ischemia. Whereas out of 400 across the front of the chest, lasting for half an hour or controls, only 20 (5%) had ischemic symptoms. The relative risk (RR) among diabetics was 2.23 (95% Blood Samples was collected between 7 AM confidence interval 1.6–2.8). The exposure rate of to 8 AM after overnight fasting. Glycosylated occurrence of ischemic heart disease in diabetics is 87% haemoglobin was estimated by standard laboratory and in non diabetics was 73%. Statistical association method as an index of long-term glycaemic control (up between the diabetics and occurrence of IHD was highly to 3 months). Resting 12-lead ECG was recorded finally to compare the diagnosis between questionnaire method Table-4 shows the sensitivity and specificity of and clinical method. A 12-lead ECG is used as the gold Rose angina questionnaire. The number in table shows standard for confirming the IHD. Probable IHD was the actual positive and negative data confirmed by defined as large Q and QS waves and possible IHD with physician diagnosed angina (by clinical examination and small Q and QS, ST depression, flattened or inverted T ECG). The Rose diagnosis of angina had 63% waves or complete left bundle branch block. Those who sensitivity, 97% specificity, 92% positive predictive value, and 97% negative predictive value. The fulfilled all these criteria were classified as having percentage of false positives is 2.48% and false negatives are 36%. The Rose Questionnaire has an subjects were selected. They were grouped as study acceptably high specificity and sensitivity. group including poorly controlled diabetics (Group A: Table-1: Distribution of IHD in different age group
diabetics (using Rose Questionnaire)
1c levels >8.0%) and well controlled diabetics Age (Years)
IHD present
IHD absent
1c levels <8.0%) based on their HbA1c levels and controls (Group C). Rose Angina questionnaire was used as a tool to detect Ischemic Heart Disease. Analysis of data thus collected was performed using SPSS version 8.0 for Windows. Continuous variables are expressed as the Mean±SD Table-2: distribution of IHD in different age
and qualitative data as percentages. Chi-square test of group non-diabetics (using Rose Questionnaire)
association was carried out to evaluate the association of Age (Years)
IHD present
IHD absent
IHD in different groups. The mean difference was taken as significant at p<0.05. Conclusion was drawn based on Table-1 shows the distribution of the subjects according Table-3: Occurrence of IHD in different groups
to the age. The youngest subject in the study group is (using Rose Angina Questionnaire)
IHD present IHD absent Total
aged 32 years and the oldest aged 68 years. The GROUP-A: HbA1C (10.32±4.87)
frequency of IHD was 1.25% in 31–40 year age group. GROUP-B: HbA1C (6.61±1.33)
This increased with age, and was 2.41% among those GROUP-C: HbA1C (5.62±1.65) Pak J Physiol 2010;6(2)
Table-4: Sensitivity and specificity of Rose Angina
prevalence of Rose angina increased with age from Questionnaire
about 1% to 12%, while the prevalence among women Chest pain present
Chest pain absent
IHD Present
IHD Absent
Age-adjusted prevalence rates of Rose angina Positive
were similar among black, white, and Mexican- American women.6,7 Another study compared the Questionnaire to exercise thallium test evidence of DISCUSSION
coronary artery disease. The Rose diagnosis of angina Ischemic heart disease is still one of the leading causes had 26% sensitivity, 79% specificity, 42% positive of Myocardial infarction, with diabetes mellitus being predictive value, and 65% negative predictive value.8 the major risk factor with an increased risk of The finding of the present study is in conformity with atherosclerosis either alone or in combination with other major risk factors such as diet, smoking, body Smith et al reported that prevalence of Rose weight etc. It has been found that patients with type-2 angina was 7.0% in black women, 4.8% in white diabetes mellitus suffer from dyslipidaemia which in women, 5.0% in black men, and 5.7% in white men turn leads to various vascular complications. The (p=0.37). Blacks were more likely to report angina if prevalence of ischemic heart disease in diabetics in they felt they were not getting needed medical care.9 present study is 1.5–4.5% in comparison with similar Reeder et al showed socio-demographic studies and values. Ischemic heart disease was seen in variation in the prevalence of cardiovascular disease in poorly controlled diabetics (16.3%), well controlled Saskatchewan. The results from the Saskatchewan Heart diabetics (6%), and controls (5%). As compared to Health Survey showed among men, the prevalence of controls and well controlled diabetics, the occurrence definite angina increased gradually with age from 1.7% of IHD is significantly higher in poorly controlled in the 18 to 34 year group, 3.8% in the 35–54 year group diabetics (Chi-square test 13.13, p<0.001). Increased to 4.8% in the 55–74 year group, while the prevalence levels of glycosylation may be a contributory factor to among women ranged from 2.5%, 4.0% to 7.1% in the develop ischemic changes in diabetic patients. Many others studied the sensitivity, specificity, Lampe et al studied chest pain by and predictive value of non-invasive testing like questionnaire and prediction of major ischemic heart questionnaire method and compared with traditional disease events in men. In the whole cohort, the relative clinical evaluation and invasive technique of vascular risks (95% CI) of a major ischemic heart disease event disease in a defined population. The findings of the were 2.03 for angina only, 2.13 for possible myocardial present study are in conformity with the earlier studies. infarction only and 4.50 for angina plus possible Rose questionnaire application to specific myocardial infarction, compared to no chest pain.11 populations such as younger women, those after MI, self administration, by mail has been examined. It has been cardiovascular risk profile.12 The Rose angina used in the Health Surveys for England and the 1984– questionnaire has been extensively used in different 1986 Scottish Heart Health Study. Heyden et cultural settings, but may not perform consistently in al2, assessed variability in response to the questionnaire different ethnic groups. The prevalence of possible Rose and suggests that this variation is a reflection of the angina and diagnosed angina in both South Asian and natural history of the disease rather than unreliability of European men was 18% and 8%, respectively. the questionnaire. The Rose questionnaire had sensitivity Sensitivity for a doctor’s diagnosis was 21% in South of 81% and a specificity of 97% when compared to Asian and 37% in European men.13,14 The findings of the present study are in conformity with these studies. Bodegard, and Murphy et al in a multivariate physician opinion in assessment of angina pectoris in the analysis reported that men with Rose angina had an Beta-Blocker Heart Attack Trial in which post- increased risk of cardiovascular death or hospitalisation 1.49 (1.33–1.66), myocardial infarction 1.63 (1.41–1.85) were treated with propranolol and half with placebo. or heart failure 1.54 (1.13–2.10) compared with men The physician diagnosis of angina identified more without angina. Angina in middle age substantially patients who suffered a subsequent fatal or nonfatal increases the risk of death, myocardial infarction, heart failure and other cardiovascular events.15,16 Questionnaire angina were investigated in white women essentially reversible, and the blood levels depend on and men aged 30 years and above who participated in both the life span of the red blood cell (average 120 the Lipid Research Clinics Program. Among men, the days) and the blood Glucose concentration. The glycated haemoglobin concentration represents the Pak J Physiol 2010;6(2)
integrated values for glucose over the preceding 6 to 8 men in the lipid research clinics program prevalence study weeks and offers a snapshot of the average blood sugar population. Am J Epidemiol 1987;125:400–9. Lacrolx AZ, Haynes SG, Savage DD, Havlik HJ. Rose
questionnaire angina among United States black, white, and Mexican-American women and men prevalence and Questionnaire into a Bahasa Melayu version and used it correlates from the second national and Hispanic health and cross-culturally, and to measure its inter-rater and intra- rater reliability.18 Ugurlu et al, showed prevalence of Cook DG, Shaper AG, Macfarlane W-Using the WHO (Rose) angina, MI and doctor-diagnosed IHD were not different Angina Questionnaire in Cardiovascular Epidemiology. between Behcet’s syndrome patients and non-Behcet’s International J Epidemiol 1989;18:607–13. syndrome controls in the whole study population and Bass E, Follansbee W, Orchard T. Comparison of a supplemented Rose questionnaire to exercise thallium testing when males and females were separately analysed.19 S in men and women. J Clin Epidemiol 1989;42:385–94. Graff-Iversen et al collected information by a short, Smith K, McGraw S, Crawford S, McKinlay J. Do blacks and three-item version of the Rose Angina Questionnaire.20 whites differ in reporting Rose questionnaire angina? Results However probably not only glycaemic optimization but of the Boston Health Care Project. Ethn Dis 1993;3:278–89. 10. Reeder B, Liu L, Horlick L. Socio-demographic variation in also lifestyle and diet intervention plays a role in the the prevalence of cardiovascular disease in Saskatchewan: improvement of the different components of diabetes results from the Saskatchewan Heart Health Survey. Can J 11. Lampe FC, Whincup P, Wannamethee S, Ebrahim S, Walker CONCLUSION
M, Shaper A. Chest pain on questionnaire and prediction of major ischaemic heart disease events in men. Eur Heart The questionnaire diagnosis showed reasonable sensitivity and high specificity as compared with 12. Nicholson A, White I, Macfarlane P, Brunner E, Marmot M. diagnosis by physician. The questionnaire method can Rose questionnaire angina in younger men and women: gender differences in the relationship to cardiovascular risk be frequently used in epidemiologic research as a standard, unbiased and validated measure of the prevalence of ischemic heart disease in general 13. Fischbacher CM, Bhopal R, Unwin N, White M, Alberti
populations. The former can be usefully incorporated in KGMM. The performance of the Rose angina questionnaire in South Asian and European origin populations: a cardiovascular risk assessment and screening programs. comparative study in Newcastle, UK. International J Epidemiol 2001;30:1009–16. ACKNOWLEDGEMENT
14. Lawlor DA, Adamson J, Ebrahim S. Performance of the Our sincere thanks to Principal of Sri Devaraj Urs WHO Rose Angina Questionnaire in Post-Menopausal Women: Are All of the Questions Necessary? Journal of Medical University for extending full support to Epidemiology and Community Health 2003;57:538–41. prepare this paper, and faculty members of 15. Bodegard J, Erikssen G, Bjornholt JV, Thelle D, Erikssen J. Department of Physiology for their kind cooperation Possible angina detected by the WHO angina questionnaire in apparently healthy men with a normal exercise ECG: coronary heart disease or not? A 26 year follow-up study. REFERENCES
16. Murphy NF, Stewart S, Hart CL, MacIntyre K, Hole Rose G. The diagnosis of ischemic heart pain and intermittent D, McMurray JJV. A population study of the long-term claudication in field surveys. Bull World Health Organ consequences of Rose angina: 20-year follow-up of the Renfrew-Paisley study. Heart 2006;92:1739–46. Heyden S, Bartel A, Tabesh E. Angina pectoris and the Rose 17. Burtis CA, Ashwood ER, Bruns DE, eds. Carbohydrates. questionnaire. Arch Intern Med 1971;128:961–4. Tietz text book of clinical chemistry and molecular Rose GA, Blackburn H, Gillum RF, Princes RJ. Cardiovascular Survey Methods, 2nd Edition, Monograph 18. Hassan N, Choudhury S, Naing L, Conroy R, Rahman A. Series No. 56, Geneva, World Health Organization; 1982. Inter-Rater and Intra-Rater Reliability of the Bahasa Melayu Version of Rose Angina Questionnaire. Asia Pac J Public
Friedman L, Byington R. The Beta Blocker Heart Attack Trial Research Group. Assessment of angina pectoris after 19. Ugurlu S, Seyahi E, Yazici H. Prevalence of angina, myocardial infarction: comparison of ‘Rose questionnaire’ myocardial infarction and intermittent claudication assessed with physician judgment in the beta-blocker heart attack by Rose Questionnaire among patients with Behcet’s trial. Am J Epidemiol 1985;121:555–62. syndrome. Rheumatology 2008;47:472–5.
Wilcosky T, Harris R, Weissfeld L. The prevalence and 20. Iversen SG, Selmer R, Lochen ML. Rose angina predicts 23- correlates of Rose questionnaire angina among women and year coronary heart disease mortality in women and men aged 40–49 years. Heart 2008;94:482–6. Address for Correspondence:
Dr. Yathish TR,
Department of Physiology, Hassan Institute of Medical Sciences, Hassan-573201, Karnataka,
India. Cell: +91-9448410163


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