Dyspnoea and atypical angina: two sides of the same coin?
Authors: Cano Carrizal R , Casanova Rodriguez C , Velez Salas A , Rodriguez Alcudia D , Martin-Penato Molina A , Cadenas Chamorro R , Iglesias Del Valle D , Paredes Gonzalez M B , De La Cruz Berlanga E , Martinez Dosantos V , Aguilera Martinez M C , Lareo Vicente A , Garcia Garcia A 
Published: January 2025

Abstract

Introduction
the latest guidelines from the European Society of Cardiology introduce dyspnoea into the risk stratification for patients with suspected coronary artery disease, equating it with atypical angina in terms of pre-test probability. Traditionally, dyspnoea has been considered an angina equivalent in certain patients, although its origin is often due to non-cardiological pathologies. Furthermore, the percentage of patients presenting with dyspnoea without chest pain and with ischaemia on stress tests varies widely across studies.

Objectives
the aims of our study were to determine the profile of patients referred to our Cardiac Imaging Unit for coronary artery disease screening whose symptom were dyspnoea or atypical angina, to assess the percentage of studies with induced ischaemia in this population, and to compare this percentage between the two groups of patients.

Methods
retrospective analysis including 626 consecutive patients who presented to our centre for stress echocardiography to screen for unknown coronary artery disease and whose referral symptons were atypical angina or dyspnoea without chest pain. To compare the probability of presenting ischaemia between the two groups, a 1:1 propensity score matching analysis was performed, incorporating traditional risk factors, as well as age, sex, body mass index (BMI), peripheral arterial vascular disease, pulmonary disease, obstructive sleep apnoea, anxiety-depressive syndrome, beta-blocker or contrast agents use, and baseline wall motion or electrocardiogram abnormalities.

Results
of the 626 patients, 149 (24%) were referred for dyspnoea without chest pain. Compared to patients presenting with atypical angina, those with dyspnoea were older (69.9 years vs 64.8 years, p&lt;0.01), had a higher BMI (29.7kg/m² vs 28.8kg/m², p=0.05), and a higher prevalence of hypertension (71% vs 58%, p=0.006), diabetes mellitus (40% vs 28%, p=0.006), dyslipidaemia (68% vs 56%, p=0.009), and pulmonary disease (24% vs 12%, p&lt;0.001). Patients referred for dyspnoea underwent pharmacological stress echocardiography more frequently (35% vs 20%, p&lt;0.001) and contrast agents were used more often (30% vs 21%, p=0.020), with basal wall motion abnormalities observed more frequently (14% vs 5%, p&lt;0.001). The percentage of studies with induced ischaemia in the dyspnoea group was slightly higher (6% vs 4%), but this difference was not statistically significant (p=0.349). Propensity matching score analysis did not reveal a higher odds of ischaemia in the dyspnoea group (OR 1.00, p=0.921, 95% CI 0.94-1.06).

Conclusions
the percentage of positive studies in patients referred for dyspnoea or atypical angina was low in both groups. Despite the higher prevalence of risk factors in the dyspnoea referral group, the likelihood of ischaemia on stress echocardiography is very similar between the two groups.
Clinical and stress characteristics
Balance plot between groups