Angiographic Disease Progression and Residual Risk of Cardiovascular Events While on Optimal Medical Therapy

Background—

The extent to which recurrent events in patients with stable coronary artery disease is attributable to progression of an index lesion originally ≥50% diameter stenosis (DS) but not revascularized or originally <50% DS is unknown during optimal medical therapy (OMT).

Methods and Results—

In the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, 205 patients assigned to OMT plus percutaneous coronary intervention (PCI) and 284 patients assigned to OMT only had symptom-driven angiograms suitable for analysis. Percentages of patients in the OMT+PCI and OMT-only cohorts with index lesions originally <50% DS were 30% and 32%, respectively; 20% and 68% had index lesions originally ≥50% DS. In both groups, index lesions originally <50% or ≥50% DS represented <4% and <25% of all such lesions, respectively. The only angiographic predictor of myocardial infarction or acute coronary syndrome was the number of lesions originally ≥50% DS that had not been revascularized (odds ratio, 1.15; confidence limits, 1.01–1.31; P <0.04).

Conclusions—

Lesions originally <50% DS were index lesions in one third of patients referred for symptom-driven repeat angiography, but represented <4% of all such lesions. Nonrevascularized lesions originally ≥50% DS were more often index lesions in OMT-only patients, but still represented a minority (<25%) of all such lesions. These findings underscore the need for improved therapies to arrest plaque progression and reliable strategies for selecting stenoses warranting PCI.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00007657.

Is cardiac catheterization necessary before initial management of patients with stable ischemic heart disease? Results from a Web-based survey of cardiologists

BACKGROUND

It is unknown whether preconceived beliefs regarding the need for cardiac catheterization and revascularization in patients with stable ischemic heart disease (SIHD) would preclude a study randomizing patients with significant ischemia to a conservative strategy. Given the widespread practice of performing revascularization in patients with SIHD, we assessed the feasibility of conducting a randomized trial comparing initial invasive and conservative strategies in patients with SIHD and moderate or severe ischemia.

METHODS

An online survey to cardiologists queried their willingness to enroll a sample patient with frequent stable angina, >10% myocardial ischemia, and normal ejection fraction into a randomized trial with a 50% chance of being conservatively managed without cardiac catheterization.

RESULTS

Among 499 respondents, 57% (95% CI 53%-62%) were willing to enroll the patient. Among 207 cardiologists unwilling to enroll, 55% (95% CI 48%-61%) would be willing if they knew the patient did not have very high-risk features on stress imaging, yielding a total of 80% (95% CI 76%-83%) of cardiologists willing to enroll. No differences were observed among different types of cardiologists (interventional, invasive/noninterventional, and noninvasive). Seventy-one percent (95% CI 67%-75%) were more likely to try initial medical therapy after the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results.

CONCLUSIONS

Most surveyed cardiologists were willing to enroll SIHD patients with at least moderate ischemia into a trial with an initial noninvasive strategy arm. These findings support the feasibility of planning a large-scale trial to test the role of cardiac catheterization and revascularization in the initial management of SIHD patients with moderate or severe ischemia.

Abstract P323: Comparison and Validation of Quality of Life Instruments in Optimally-Treated Stable Coronary Patients

Background: Measures of quality of life and health status have become important outcomes in clinical trials and in economic evaluations of medical interventions. Even if these measures were from validated instruments, it is necessary to check the instruments' reliability and validity with on-going trial subjects.

Methods: We used three years of data from the COURAGE study, a randomized trial evaluating the outcomes of optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI) in a total of 2,287 patients with stable Coronary disease. We assessed angina-specific health status via SAQ, overall physical and mental function via RAND-36, and a single, preference-based index measure of health via standard gamble based utility.

Results: Intra-class coefficients for SAQ were from 0.33 to 0.53, for RAND-36 were from 0.45 to 0.69 in each domain, but was only 0.27 for utility, suggesting that SAQ and RAND-36 were assessments with good consistency and reproducibility, but utility was not. SAQ and RAND-36 were shown to be instruments with trusted internal consistency reliability: Cronbach's alpha values from subscale scores for SAQ were from 0.6 to 0.9, and for RAND-36 were from 0.77 to 0.93; for SAQ as an instrument of angina status were from 0.74 to 0.80, for RAND-36 as an instrument of general health status were from 0.90 to 0.93 across time. The coefficients of variation were 0.38 to 0.60 for each domain of SAQ and 0.33 to 0.82 for each domain of RAND-36, but less than 0.24 for utility across time, indicating that SAQ and RAND-36 reflected the impact of treatment over time, while utility did not. The Canadian Cardiovascular Society Classification, a widely used system for grading angina severity of symptoms, was highly related to baseline scores in each domain of SAQ and RAND-36, but not to the baseline utility, indicating that utility was problematic in measuring the differences in angina severity.

Conclusions: For stable coronary patients, SAQ was the most reliable instrument in COURAGE, although there is need to consider variation of scores in each domain; RAND-36 while also reliable, was not as good for angina as SAQ; utility from standard gamble program was not a good instrument due to the ceiling effect and we should be cautions about its use.

Abstract P173: Risk Factor Analysis of Clinically Significant Improvements in Quality of Life Measures for Stable Coronary Patients

Background: The COURAGE trial compared percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) to OMT alone in reducing the risk of cardiovascular events in 2287 patients with stable coronary disease. We examined the impact of PCI and other risk factors on clinically significant improvements in quality of life measures.

Methods: Angina-specific and overall health status were assessed with the Seattle Angina Questionnaire (SAQ) and RAND-36 respectively, at baseline and at 1, 3, 6 and 12 months followed by annual evaluations. Scores range from 0 to 100; higher scores indicate better health status. Clinically significant improvement from baseline within individual patients was defined as score increases of ≥8, ≥25, ≥20, ≥12, and ≥16 for physical limitation, angina stability, angina frequency, treatment satisfaction, and quality of life domains respectively in SAQ and ≥ 10 for each domain in RAND-36.

Results: Adjusted for other demographic and comorbidity risk factors, adding PCI to OMT resulted in clinically significant improvements in physical limitation from 1 to 6 months, angina stability from 1 to 3 months, angina frequency from 1 to 36 months, treatment satisfaction no time, and quality of life from 1 to 6 months in SAQ (p-value<0.05); For RAND-36, adding PCI to OMT resulted in clinically significant improvements in physical functioning from 1 to 6 months, energy/fatigue from 1 to 3 months, emotional well-being from 1 month to 3 months, pain at 1 month, but no time in other domains. Overall important interactions between treatment (adding PCI to OMT) and follow-up time were found in all domains of SAQ except in angina stability, but not found in all domains of RAND-36, indicating that the impact of PCI on angina specific health varies over time. Age and historic clinical events such as previous diabetes, congestive heart failure, or myocardial infarction previous were also shown to be important risk factors for clinically significant improvements, especially after loss of the influence of PCI.

Conclusions: Adding PCI to OMT significantly improved angina-related health clinically from 3 to 6 or 12 months, but less for overall general health status. There was no advantage to PCI after about 1 year in any clinically significant improvement.

Abstract 11: Predicting Angina for Stable Coronary Patients with or Without Percutaneous Coronary Intervention

Background: Relief of angina and improvement in quality of life is the most common indication for percutaneous coronary intervention (PCI) in stable ischemic heart disease (SIHD). Given that there are alternative strategies for treating angina, (e.g. intensifying optimal medical therapy (OMT) or PCI), predicting angina severity as a function of alternative treatment options can serve as a foundation for shared decision-making and the elicitation of patients’ preferences.

Methods: Using data from the 2,287 SIHD patients in COURAGE trial, where PCI was randomized, we built multivariable linear regression models of Seattle Angina Questionnaire (SAQ)-assessed angina, physical function and quality of life at 6 and 12 months, using baseline SAQ scores, treatment, and all demographic and clinical characteristics available at the time of randomization.

Results: At baseline, there were no significant differences between PCI and OMT groups for any SAQ domain. The strongest predictors of 6- and 12-month SAQ scores were patients’ baseline scores. Different characteristics had different degrees of association with angina, physical function and quality of life domains, with PCI being associated with 1.9-5.3-point greater improvement in SAQ scores, depending upon the domain and time frame. The adjusted R 2 of final models varied from 0.38-0.62. The results (regression coefficients with standard errors and adjusted R 2 ) of patients characteristics associated with SAQ scores for 6-month and 1-year are presented in table.

Conclusions: Prediction models can be created to estimate patient-centered health status outcomes and could be used as an evidence-based foundation for supporting shared medical decision-making in SIHD. The impact of such models on treatment decisions needs to be assessed in future studies.

Abstract P181: Myocardial Infarction Treatment: Gender Disparity

Purpose: Rapid time of reperfusion of the infarct-related artery is a key element in the treatment of acute myocardial infarction (MI). Prompt recognition of MI can be challenging in women because of the frequency of atypical symptoms. Our purpose is to determine whether the time to coronary catheterization (cath) differs between men and women.

Methods: We conducted a retrospective study of all patients admitted at an academic medical center for whom troponin (cTn) levels were measured between 2004 and 2010. ICD9 codes were used to identify patients with MI. Chi-square and Wilcoxon-rank sum test were used to compare demographic and clinical characteristics between genders. Multiple linear regression (MLR) was used to predict time to cath according to gender after adjusting for kidney function, age, race, diabetes, hypertension, cTn levels and type of MI: ST-segment elevation (STEMI) or non-ST elevation (NSTEMI). We examined the interaction between type of MI and gender.

Results: Our study population included 2354 patients with MI who had a cath. Among them 31.4% were women, 38.4% were older than 65 years, 11.7% black. Women were older than men (mean age 65.2 versus 59.6, p<0.0001), less likely to have diabetes (67.9% versus 72.7%, p=0.0178) but more likely to have hypertension (75.1% versus 69.4% p=0.0047) more likely to have chronic kidney disease defined as GFR<60 mL/min/1.73m 2 (30.9% versus 16.0%, p<0.001). Less women than men had STEMI (48.3% versus 56.4%, p=0.0003). In STEMI as well as in NSTEMI, median time to cath was longer in women (STEMI: 70 versus 65 minutes, p=0.0364; NSTEMI: 26.5 hours versus 22.5 hours, p<0.0001). Results from the MLR showed that the interaction between gender and type of MI was significant (p=0.0010). In NSTEMI patients, adjusted means in time to cath were 4.6 hours longer (p<0.0001) in women than men (25.9 hours versus 30.5 hours ).There was no difference in STEMI patients (p=0.874).

Conclusion: Appropriate treatment seems to be delayed in women with NSTEMI. Reason for this treatment disparity should be elucidated.

Prevalence and outcomes of same-day discharge after elective percutaneous coronary intervention among older patients

CONTEXT

Patients undergoing elective percutaneous coronary intervention (PCI) are generally observed overnight in the hospital. The association between same-day discharge of older patients and death or readmission is unclear.

OBJECTIVE

To evaluate the prevalence and outcomes of same-day discharge among older patients undergoing elective PCI in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter cohort study. Data were from 107,018 patients 65 years or older undergoing elective PCI procedures at 903 sites participating in the CathPCI Registry between November 2004 and December 2008 and were linked with Medicare Part A claims. Patients were divided into 2 groups based on their length of stay after PCI: same-day discharge or overnight stay.

MAIN OUTCOME MEASURES

Death or rehospitalization occurring within 2 days and by 30 days after PCI.

RESULTS

The prevalence of same-day discharge was 1.25% (95% CI, 1.19%-1.32%; n = 1339 patients) with significant variation across facilities. Patient characteristics were similar between the 2 groups, although same-day discharge patients underwent shorter procedures with less multivessel intervention. There were no significant differences in the rates of death or rehospitalization at 2 days (same-day discharge, 0.37% [95% CI, 0.16%-0.87%] vs overnight stay, 0.50% [95% CI, 0.46%-0.54%]; P = .51) or at 30 days (same-day discharge, 9.63% [95% CI, 8.17%-11.33%] vs overnight stay, 9.70% [95% CI, 9.52%-9.88%]; P = .94). Among patients with adverse outcomes, the median time to death or rehospitalization did not differ significantly between the groups (same-day discharge, 13 days [interquartile range, 7.0-21.0] vs overnight stay, 14 days [interquartile range, 7.0-21.0]; P = .96). After adjustment for patient and procedure characteristics, same-day discharge was not significantly associated with 30-day death or rehospitalization (adjusted odds ratio, 0.95 [95% CI, 0.78-1.16]).

CONCLUSION

Among selected low-risk Medicare patients undergoing elective PCI, same-day discharge is rarely implemented but is not associated with death or rehospitalization compared with overnight observation.

Determinants of excessive daytime sleepiness and fatigue in adults with heart failure

Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern United States. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score > 10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p = .048), worse functional class (p = .004), not taking a diuretic (p = .005), and lack of physical activity (p = .04). Only sleep quality was associated with fatigue (p < .001). Sleep-disordered breathing was not significantly associated with EDS or with fatigue. These factors may be amenable to intervention.

Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association

The process of atherosclerosis may begin in youth and continue for decades, leading to both nonfatal and fatal cardiovascular events, including myocardial infarction, stroke, and sudden death. With primordial and primary prevention, cardiovascular disease is largely preventable. Clinical trial evidence has shown convincingly that pharmacological treatment of risk factors can prevent events. The data are less definitive but also highly suggestive that appropriate public policy and lifestyle interventions aimed at eliminating tobacco use, limiting salt consumption, encouraging physical exercise, and improving diet can prevent events. There has been concern about whether efforts aimed at primordial and primary prevention provide value (ie, whether such interventions are worth what we pay for them). Although questions about the value of therapeutics for acute disease may be addressed by cost-effectiveness analysis, the long time frames involved in evaluating preventive interventions make cost-effectiveness analysis difficult and necessarily flawed. Nonetheless, cost-effectiveness analyses reviewed in this policy statement largely suggest that public policy, community efforts, and pharmacological intervention are all likely to be cost-effective and often cost saving compared with common benchmarks. The high direct medical care and indirect costs of cardiovascular disease-approaching $450 billion a year in 2010 and projected to rise to over $1 trillion a year by 2030-make this a critical medical and societal issue. Prevention of cardiovascular disease will also provide great value in developing a healthier, more productive society.

Symptom clusters and health-related quality of life in people with chronic stable angina

AIM

This paper reports findings of a study to examine the independent contribution of chest pain, fatigue and dyspnoea to health-related quality of life in people with chronic stable angina.

BACKGROUND

People with chronic stable angina experience poorer quality of life in multiple areas including physical and emotional health. Emerging evidence suggests the presence of concomitant symptoms yet there are no systematic studies examining the impact of symptom clusters on quality of life in people with chronic angina.

METHOD

Outpatients (n = 134), recruited over a 16-month period in 2000 and 2001, with confirmed coronary heart disease and chronic angina completed reliable and valid questionnaires measuring chest pain frequency, fatigue, dyspnoea and quality of life. The data have contemporary relevance because despite changes in treatment of coronary heart disease, chronic angina remains prevalent worldwide. Hierarchical multiple linear regression was used to examine the symptom cluster of chest pain frequency, fatigue and dyspnoea in predicting quality of life.

RESULTS

The sample was predominantly white (74·6%), men (59·7%) with a mean age of 63·4 (sd 12·12) years. Controlling for age, gender, social status and co-morbidities, the symptom cluster of chest pain frequency, dyspnoea and fatigue accounted for a statistically significant increase in unadjusted R² (F of Δ, P < 0·05) for the models predicting physical limitation (R² Δ 24·1%), disease perception (R² Δ 24·6%), Short Form-36 Physical Component Score (R² Δ 24·3%) and Mental Component Score (R² Δ 07·0%).

CONCLUSION

Symptom assessment and management of people with chronic stable angina should involve multiple symptoms. Greater fatigue predicted poorer quality of life in multiple areas. As a possible indicator of depression, it warrants further assessment and follow-up.

The Cost-Effectiveness of Percutaneous Coronary Intervention as a Function of Angina Severity in Patients With Stable Angina

Background—

The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial compared percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) to OMT alone in reducing the risk of cardiovascular events in 2287 patients with stable coronary disease. We examined the cost-effectiveness of PCI as a function of angina severity at the time of randomization.

Methods and Results—

Angina severity was assessed with the Seattle Angina Questionnaire (SAQ). Patients were grouped into tertiles based on the distribution of baseline scores such that higher tertiles represented better health status. Clinically significant improvement from baseline within individual patients was defined as score increases of >8 for physical limitation, >20 for angina frequency, and >16 for quality-of-life domains. The incremental cost-effectiveness ratio for PCI was calculated as the difference in costs divided by the difference in proportion of patients with clinically significant improvement. Improvement in angina severity was significantly greater for PCI patients in the lowest and middle tertiles. The number of patients needed to treat was much larger for the highest tertile. The added in-trial cost of PCI ranged from $7300 to $13 000. Incremental cost-effectiveness ratios ranged from $80 000 to $330 000 for the lowest and middle tertiles and from $520 000 to >$3 million for the highest tertile for 1 additional patient to achieve significant clinical improvement in health status.

Conclusions—

The incremental cost of PCI to provide meaningful clinical benefit above that achieved by OMT alone was lower for patients with severe angina than for those with mild or no angina. However, it is uncertain that at any level of angina severity that PCI as an initial strategy would achieve a socially acceptable cost threshold.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00007657.

Acceptance, panic, and partial recovery the pattern of usage of drug-eluting stents after introduction in the U.S. (a report from the American College of Cardiology/National Cardiovascular Data Registry)

OBJECTIVES

Review the use of drug-eluting stents (DES) to evaluate changes in use.

BACKGROUND

The DES were approved after several small studies in carefully selected patients showed dramatic reduction in in-stent restenosis. The DES were then rapidly adopted into routine practice. In 2006, 3 years after introduction, serious concerns regarding long-term safety were raised.

METHODS

We queried the American College of Cardiology/National Cardiovascular Data Registry (ACC/NCDR) CathPCI Registry. The percentage of DES used through mid-2009 was reviewed overall and in subgroups of patients categorized by lesion type, clinical factors, insurance, and hospital characteristics. Multivariable logistic models relating these covariates to DES usage were constructed for 3 relevant time intervals.

RESULTS

A total of 2,247,647 coronary stent procedures were analyzed. By 2005 over 90% of first stents placed were DES. Safety concerns arising in 2006 reduced DES use to 64% of first stent placed. After publication of salutary outcomes data in 2008, usage increased to 76% by mid-2009. The logistic models demonstrated decreased likelihood of DES usage in patients with: 1) ST-segment elevation myocardial infarctions; and 2) no medical insurance. The DES usage increased for in-stent restenosis. Hospital characteristics were not associated with significant differences in DES usage.

CONCLUSIONS

There was rapid adoption of DES into U.S. clinical practice. Concern for late stent thrombosis in 2006 significantly altered DES use with reductions seen in subgroups at risk for thrombosis and patients with no insurance. These rapid cyclic changes after DES introduction reinforce the need for continuous, timely reporting of outcomes data after the introduction of new technologies.