Importance of Angina Pectoris by Coronary Artery Disease Severity

Importance Angina pectoris remains a common clinical manifestation, but contemporary population-based data on its long-term prognostic significance are limited. Objective To evaluate the long-term importance of angina pectoris in association with coronary artery disease (CAD) severity determined by coronary computed tomography angiography (CCTA) in a general population. Design, Setting, and Participants This population-based cohort study included participants from the Swedish Cardiopulmonary Bioimage Study who had completed the Rose Questionnaire and underwent valid CCTA from November 2013 to October 2018, excluding participants with prior myocardial infarction (MI), heart failure, or coronary revascularization. Follow-up continued through September 2024. Data analyses were conducted between August 2025 and January 2026. Exposures Angina (defined by the Rose Questionnaire) and CAD (categorized as no findings, nonobstructive CAD [<50% stenosis], or obstructive CAD [≥50% stenosis]) according to CCTA findings. Main Outcomes and Measures The primary outcome was MI or coronary death. The secondary outcome was major adverse cardiac events (MACE), defined as MI, coronary revascularization, heart failure hospitalization, or death from coronary disease or heart failure. Associations were evaluated using Cox regression with sequential multivariable adjustment and stratification by CAD category and presented as hazard ratios (HRs). Results This study included 24 176 individuals (median [IQR] age, 57 [54-61] years; 12 225 female [50.6%]; 1615 with hyperlipidemia [6.8%]; 4374 with hypertension [18.3%]; 703 with diabetes [2.9%]). Angina was present in 720 participants (3.0%). During a median (IQR) follow-up of 7.7 (6.9-8.6) years, 293 primary events occurred. Angina was associated with a higher incidence of MI or coronary death compared with no angina (21 participants [2.9%] vs 272 participants [1.2%]; HR, 2.50; 95% CI, 1.60-3.90). Event rates increased across CAD categories, with no evidence of interaction between angina and CAD severity. After multivariable adjustment, angina remained independently associated with the primary outcome (HR, 1.65; 95% CI, 1.04-2.63). Similar associations were observed for MACE (adjusted HR, 2.34; 95% CI, 1.73-3.16). Conclusions and Relevance In this cohort study of a contemporary general population, angina pectoris was associated with adverse cardiac outcomes, independent of CAD severity assessed by CCTA. These findings suggest that symptom assessment remains relevant in cardiovascular risk stratification because it provided incremental prognostic information that may reflect underlying coronary microvascular dysfunction or vasomotor disorders.