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

A large number of angina patients remain undiagnosed and, as a result, are under-treated.

“A sad fact is that many doctors are not picking up that their patients have angina,” said 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 causes of angina.”  

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

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. Indeed, a Yale cardiology study 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.  

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.  

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. Said 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 SA. Therefore, primary care doctors need to take the initiative with a careful history to detect suggestive symptoms of CVD and possible angina.”  

Pharmacists are uniquely positioned to encourage patients to see their GP or a cardiologist should they complain of angina symptoms. These may include chest discomfort, fatigue, breathing difficulties, arm pain, nausea, and neck pain. That said, the Yale study 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.   

It’s important 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 SA is skewed towards surgical interventions, as opposed to optimal medical therapy (OMT). This is contrary to what consistent scientific evidence and international treatment guidelines suggest. Only 25% of patients who might have benefitted (average age 65 years) were treated with OMT as the initial management approach. In a rural SA population, only 6% of those with angina were receiving treatment at all.  

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 SA.