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Zhang Z, Jones P, Weintraub WS, Mancini GBJ, Sedlis S, Maron DJ, Teo K, Hartigan P, Kostuk W, Berman D, Boden WE, Spertus JA. Predicting the Benefits of Percutaneous Coronary Intervention on 1-Year Angina and Quality of Life in Stable Ischemic Heart Disease: Risk Models From the COURAGE Trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation). Circ Cardiovasc Qual Outcomes 2019; 11:e003971. [PMID: 29752388 DOI: 10.1161/circoutcomes.117.003971] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 02/16/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is a therapy to reduce angina and improve quality of life in patients with stable ischemic heart disease. However, it is unclear whether the quality of life after PCI is more dependent on the PCI or other patient-related factors. To address this question, we created models to predict angina and quality of life 1 year after PCI and medical therapy. METHODS AND RESULTS Using data from the 2287 stable ischemic heart disease patients randomized in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) to PCI plus optimal medical therapy (OMT) versus OMT alone, we built prediction models for 1-year Seattle Angina Questionnaire angina frequency, physical limitation, and quality of life scores, both as continuous outcomes and categorized by clinically desirable states, using multivariable techniques. Although most patients improved regardless of treatment, marked variability was observed in Seattle Angina Questionnaire scores 1 year after randomization. Adding PCI conferred a greater mean improvement (about 2 points) in Seattle Angina Questionnaire scores that were not affected by patient characteristics (P values for all interactions >0.05). The proportion of patients free of angina or having very good/excellent physical limitation (physical function) or quality of life at 1 year was 57%, 58%, 66% with PCI+OMT and 50%, 55%, 59% with OMT alone group, respectively. However, other characteristics, such as baseline symptoms, age, diabetes mellitus, and the magnitude of myocardium subtended by narrowed coronary arteries were as, or more, important than revascularization in predicting symptoms (partial R2=0.07 versus 0.29, 0.03 versus 0.22, and 0.05 versus 0.24 in the domain of angina frequency, physical limitation, and quality of life, respectively). There was modest/good discrimination of the models (C statistic=0.72-0.82) and excellent calibration (coefficients of determination for predicted versus observed deciles=0.83-0.97). CONCLUSIONS The health status outcomes of stable ischemic heart disease patients treated by OMT+PCI versus OMT alone can be predicted with modest accuracy. Angina and quality of life at 1 year is improved by PCI but is more strongly associated with other patient characteristics. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00007657.
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Affiliation(s)
- Zugui Zhang
- Christiana Care Health System, Newark, DE (Z.Z.)
| | - Philip Jones
- Mid-America Heart Institute/University of Missouri-Kansas City (P.J., J.A.S.)
| | | | | | - Steven Sedlis
- New York Veterans Affairs Medical Center and New York University (S.S.)
| | | | - Koon Teo
- McMaster University, Hamilton, ON, Canada (K.T.)
| | - Pamela Hartigan
- Cooperative Studies Program Coordinating Center, Veterans Affairs Connecticut Healthcare System, West Haven (P.H.)
| | | | | | - William E Boden
- Veterans Affairs New England Healthcare System, Massachusetts Veterans Epidemiology, Research, and Informatics Center, Boston (W.E.B.)
| | - John A Spertus
- Mid-America Heart Institute/University of Missouri-Kansas City (P.J., J.A.S.)
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Khatib R, Marshall K, Silcock J, Forrest C, Hall AS. Adherence to coronary artery disease secondary prevention medicines: exploring modifiable barriers. Open Heart 2019; 6:e000997. [PMID: 31354954 PMCID: PMC6615814 DOI: 10.1136/openhrt-2018-000997] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/14/2019] [Accepted: 06/13/2019] [Indexed: 12/17/2022] Open
Abstract
Background Non-adherence to secondary prevention medicines (SPMs) among patients with coronary artery disease (CAD) remains a challenge in clinical practice. This study attempted to identify actual and potential modifiable barriers to adherence that can be addressed in cardiology clinical practice. Methods This was a cross-sectional, postal survey-based study of the medicines-taking experience of patients with CAD treated at a secondary/tertiary care centre. All participants had been on SPM for ≥3 months. Results In total, 696 eligible patients were sent the survey and 503 responded (72.3%). The median age was 70 years, and 403 (80.1%) were male; the median number of individual daily doses of all medicines was 6. The rate of non-adherence to at least one SPM was 43.5% (n=219), but 53.3% of reported non-adherence was to only one SPM. Statins contributed to 66.7% and aspirin to 61.7% of overall non-adherence identified by the Single Question (SQ) tool. In 30.8% of non-adherent patients (n=65), this was at least partly intentional. Barriers included forgetfulness (84.9%; n=186), worry that medicines will do more harm than good (33.8%; n=74), feeling hassled about medicines taking (18.7%; n=41), feeling worse when taking medicines (14.2%; n=31) and not being convinced of the benefit of medicines (9.1%; n=20). In a multivariate analysis, modifiable factors associated with overall non-adherence included being prescribed aspirin (OR: 2.22; 95% CI: 1.18 to 4.17), having specific concern about SPM (OR: 1.12; 95% CI: 1.07 to 1.18) and issues with repeat prescriptions (OR: 2.48; 95% CI: 1.26 to 4.90). Different factors were often associated with intentional versus unintentional non-adherence. Conclusions Using appropriate self-report tools, patients share actual and potential modifiable barriers to adherence that can be addressed in clinical practice. Non-adherence behaviour was selective. Most non-adherence was driven by forgetfulness, concern about the harm caused by SPM and practical barriers.
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Affiliation(s)
- Rani Khatib
- Medicines Management & Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Cardiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Kay Marshall
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Jon Silcock
- Bradford School of Pharmacy, University of Bradford, Bradford, UK
| | - Claire Forrest
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Alistair S Hall
- Cardiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Lu Y, Zhang H, Wang Y, Zhou T, Welsh J, Liu J, Guan W, Li J, Li X, Zheng X, Spertus JA, Masoudi FA, Krumholz HM, Jiang L. Percutaneous Coronary Intervention in Patients Without Acute Myocardial Infarction in China: Results From the China PEACE Prospective Study of Percutaneous Coronary Intervention. JAMA Netw Open 2018; 1:e185446. [PMID: 30646292 PMCID: PMC6324328 DOI: 10.1001/jamanetworkopen.2018.5446] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Despite a rapid increase in percutaneous coronary intervention (PCI) procedures in China, little is known about patient-reported health status before and after PCI in patients without acute myocardial infarction (AMI). OBJECTIVE To describe self-perceived angina-specific health status prior to PCI and 1 year after the procedure in patients without AMI in China. DESIGN, SETTING, AND PARTICIPANTS The China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Prospective Study of PCI was a population-based, multicenter cohort study of a consecutive sample of 1611 patients without AMI undergoing elective PCI. Participants were enrolled from 40 hospitals in 18 provinces in China from December 2012 to August 2014. Participants were eligible if they underwent PCI for stable and unstable angina and did not have AMI. Participants were excluded if they died in hospital, withdrew from follow-up, or had missing data on self-reported health status at baseline or at 1 year after PCI. The date of the analysis was September 15, 2018. EXPOSURES Percutaneous coronary intervention for ischemic heart disease. MAIN OUTCOMES AND MEASURES Angina frequency and angina-related quality of life were assessed with the Seattle Angina Questionnaire (SAQ) immediately prior to PCI and 1 year after the procedure. Either (1) an increase in the SAQ Angina Frequency score of 10 or more points or (2) an increase in the SAQ Quality-of-Life score of 10 or more points was considered to represent clinically significant improvement. RESULTS Of 1611 patients, 520 (32.3%) were women; mean (SD) age was 61.3 (9.8) years. Among these patients, 443 (27.5%) had stable coronary artery disease and 1168 (72.5%) had unstable angina. One hundred fourteen of 443 patients undergoing PCI for stable coronary artery disease (25.7%) and 175 of 1168 undergoing PCI for unstable angina (15.0%) had no reported angina symptoms at the time of the procedure (SAQ Angina Frequency score = 100). Moreover, 18% of all patients (290) had minimal angina symptoms (SAQ Angina Frequency score >90) and, thus, no potential for substantial clinical improvement. Patients with smaller clinical improvements in angina symptom burden at 1 year following PCI had significantly higher baseline SAQ scores for all scales than patients with greater clinical improvement, but generally similar sociodemographic and procedural characteristics. CONCLUSIONS AND RELEVANCE In this study, 25.7% of patients undergoing PCI for stable coronary artery disease had no reported angina symptoms at the time of the procedure. Patients with smaller clinical improvements in angina symptom burden had higher baseline SAQ scores, which highlights the importance of ascertaining impairment from angina among patients without AMI prior to performing PCI.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Haibo Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Tianna Zhou
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
| | - John Welsh
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
| | - Jiamin Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Wenchi Guan
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - Xin Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
| | - John A. Spertus
- Health Outcomes Research, Saint Luke’s Mid America Heart Institute/University of Missouri-Kansas City, Kansas City
| | | | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale University/Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- NHC Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, People’s Republic of China
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Kureshi F, Jones PG, Buchanan DM, Abdallah MS, Spertus JA. Variation in patients' perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study. BMJ 2014; 349:g5309. [PMID: 25200209 PMCID: PMC4157615 DOI: 10.1136/bmj.g5309] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers. DESIGN Cross sectional study. SETTING 10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011. PARTICIPANTS 991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention. MAIN OUTCOME MEASURES Patients' perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients' understanding across centers and operators after adjusting for patient characteristics, using median odds ratios. RESULTS The most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients' perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site. CONCLUSION Patients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.
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Affiliation(s)
- Faraz Kureshi
- Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA University of Missouri- Kansas City, Kansas City, MO, USA
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA
| | - Donna M Buchanan
- Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA University of Missouri- Kansas City, Kansas City, MO, USA
| | - Mouin S Abdallah
- Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA University of Missouri- Kansas City, Kansas City, MO, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO 64111, USA University of Missouri- Kansas City, Kansas City, MO, USA
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