A comparison of quality of life scores in patients with angina pectoris after angioplasty compared with after medical therapy. Outcomes of a randomized clinical trial. Veterans Affairs Study of Angioplasty Compared to Medical Therapy Investigators

Factors associated with health-related quality of life in patients undergoing percutaneous coronary intervention: Thai PCI registry

Background

Percutaneous coronary intervention (PCI) has been shown to improve health-related quality of life (HRQoL) in patients with coronary artery disease (CAD). The objectives of this study were to assess the changes in HRQoL and factors influencing these changes in CAD patients after undergoing PCI.

Methods

Data from a nationwide PCI registry across 39 hospitals in Thailand were collected in 2018-2019, including baseline characteristics, comorbid diseases, angiographic CAD severity, procedural details, and type of health insurance. HRQoL, as measured by utility scores, was determined in all patients using the Thai version of EQ-5D-5l at admission, discharge, and 6 and 12 months after discharge. The effects of time after PCI procedure and various factors on mean utility scores were assessed using a mixed-effect linear regression model.

Results

A total of 19,701 patients were included in the analysis; they had a mean age of 64.2 ± 11.7 years and were predominantly (69.1%) male. Following PCI, the mean utility scores increased from 66.6 ± 19.6 at admission to 81.9 ± 13.8 at discharge, and remained stable at 6 and 12 months (86.1 ± 12.3 and 88.0 ± 11.7, respectively). After adjusting for potential confounding variables, several factors were found to be independently associated with improved HRQoL, including angiographic success, male gender, overweight status, dyslipidemia, and radial access. Six other factors were associated with less improved HRQoLs, including cardiogenic shock/IABP support, old age, CKD, clinical presentation (STEMI and NSTEMI), prior cerebrovascular disease, and heart failure. There were no associations of CAD severity and procedural details with HRQoL. No differences were found related to type of health insurance, except that patients who were uninsured or self-pay tended to have less improvement in HRQoL.

Conclusion

HRQoL improved significantly after PCI in these subjects, as observed through 1 year of follow-up. Identifying the factors influencing these improvements may assist clinicians in tailoring patient interventions to optimise quality of life after PCI.

Health-Related Quality of Life After Percutaneous Coronary Intervention for Stable Ischemic Heart Disease: A Systematic Review and Meta-analysis

BACKGROUND

There has been no meta-analysis of whether percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) improves health-related quality of life (HRQL) compared with OMT alone in patients with stable ischemic heart disease (SIHD).

METHODS

We searched MEDLINE, Cochrane Central Registry of Controlled Trials, Embase, ClinicalTrials.gov, and International Clinical Trials Registry Platform in November 2022. We included randomized controlled trials (RCTs) that compared PCI with OMT vs OMT alone with HRQL in patients with SIHD. The primary outcome was the aggregated physical HRQL, including physical functioning using the Short Form (SF)-36 or RAND-36, physical limitation using the Seattle Angina Questionnaire (SAQ) or SAQ-7, McMaster Health Index Questionnaire, and Duke Activity Status Index within 6 months. Data were analyzed using a random effects model when substantial heterogeneity was identified or a fixed effect model otherwise.

RESULTS

Among 14 systematically reviewed RCTs, 12 RCTs with 12,238 patients were meta-analyzed. Only 1 trial had a low risk of bias in all domains. PCI with OMT improved aggregated physical HRQL (standardized mean difference, 0.16; 95% confidence interval [CI], 0.1-0.23; P < 0.0001) at 6 months. Also, PCI with OMT improved physical functioning on the SF-36/RAND-36 (mean difference 3.65; 95% CI, 1.88-5.41) and physical limitation on the SAQ/SAQ-7 (mean difference, 3.09; 95% CI, 0.93-5.24) compared with OMT alone at 6 months. However, all of the aggregated physical HRQL domains were classified into small effects, and no HRQL domain exceeded the prespecified minimal clinically important difference.

CONCLUSIONS

These findings showed that PCI with OMT improved HRQL compared with OMT alone in patients with SIHD, but the benefit was not large.

Popular procedures without evidence of benefit: A case study of percutaneous coronary intervention for stable coronary artery disease

Despite limited benefit, percutaneous coronary intervention (PCI) remains a common procedure that is often performed for uncertain or inappropriate indications in patients with stable coronary artery disease (CAD). PCI cases per capita have increased year-over-year in most European countries, and many have higher rates than the U.S. Meanwhile, first-line therapy such as optimal medical therapy (OMT) and lifestyle changes, continue to be under-utilized. This article reviews the evidence on use of PCI in stable CAD. Specifically, we analyzed randomized control trials, systematic reviews, appropriate use criteria, and professional society guidelines that examine the risks and benefits of PCI compared to OMT. We then highlight utilization patterns as well as interventions that better align current practice with evidence-based care.

Quality of Life Assessment in Trials of Revascularization for Chronic Stable Angina: Insights from ORBITA and the Implications of Blinding

The main aims of therapy in chronic stable angina are to reduce the risk of myocardial infarction and death and improve symptoms and quality of life (QoL). Unblinded trials have shown that revascularization does not reduce the risk of myocardial infarction or death but does appear to improve symptoms. However, symptoms are susceptible to the placebo effect which can bias therapies to appear more effective than they are. To assess the true physical impact of a treatment on symptoms, placebo-controlled trials with patients and medical and research teams blinded to treatment allocation are necessary. Symptoms and QoL can be reported directly by the patient or indirectly by the physician. Patient-reported outcome measures in angina trials can include angina frequency, frequency of nitrate use, exercise capacity, and questionnaires such as the Seattle Angina Questionnaire (SAQ) and the generic EuroQOL-5D-5L (EQ-5D-5L) QoL questionnaire. Physician-assessed outcome measures include Canadian Cardiovascular Society Class. The Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was the first blinded placebo-controlled study investigating the role of percutaneous coronary intervention (PCI) in chronic stable angina. The trial showed a smaller than expected and not statistically significant effect of placebo-controlled PCI on the primary endpoint of change in exercise time at 6 weeks follow-up in single-vessel coronary artery disease. There was also no significant placebo-controlled treatment effect of PCI for the prespecified secondary endpoints of SAQ or EQ-5D-5L, although PCI did result in 20% more patients becoming free from angina than placebo in a non-prespecified secondary analysis. ORBITA has demonstrated the need for symptomatic and QoL effects of PCI to be studied using placebo control. Here, we describe ways of measuring QoL, the impact of the unblinded and blinded trials to date, what we have learned from ORBITA, and what is next for this common and complex condition.

Sex Differences in 1-Year Health Status Following Percutaneous Coronary Intervention in Patients Without Acute Myocardial Infarction: Results From the China PEACE Prospective Study

Background

Sex differences in health status outcomes after percutaneous coronary intervention among patients without acute myocardial infarction are not well described.

Methods and Results

A total of 2237 patients (33.4% women) without acute myocardial infarction undergoing percutaneous coronary intervention were enrolled from 39 Chinese tertiary hospitals in the PEACE (China Patient‐centered Evaluative Assessment of Cardiac Events) prospective percutaneous coronary intervention study. Data were collected immediately before and 1 year following percutaneous coronary intervention. Health status was measured using the disease‐specific Seattle Angina Questionnaire (SAQ) Angina Frequency and Quality of Life domains, as well as the SAQ Summary Score. Among the study population, women were older, more often single, had lower levels of education, and had a higher prevalence of cardiac risk factors such as hypertension and diabetes mellitus. Women had lower mean 1‐year SAQ Angina Frequency scores (mean±SD, 91.0±17.3 versus 93.9±13.3; P<0.01), SAQ Quality of Life scores (mean±SD, 67.3±23.0 versus 70.6±21.6; P<0.01), and SAQ Summary Scores (mean±SD, 81.6±13.8 versus 84.8±11.9; P<0.01), a difference of marginal clinical significance that persisted after multivariable adjustment. A slightly larger improvement in the SAQ Summary Score was observed in women as compared with men (20.9±22.6 versus 18.5±21.3; P=0.007) in unadjusted analysis. However, women were less likely to achieve clinically significant improvement in SAQ Angina Frequency (adjusted odds ratio, 0.67; 95% CI, 0.45–1.00) and SAQ Quality of Life (adjusted odds ratio, 0.73; 95% CI, 0.56–0.96) after adjustment.

Conclusions

There were no clinically significant differences in 1‐year health status outcomes and improvement in health status by sex among patients without acute myocardial infarction following percutaneous coronary intervention. However, female sex was associated with poorer 1‐year health status and a lower likelihood of experiencing clinically improvement in health status.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01624922.

Real-world Evidence for the Antianginal Efficacy of Trimetazidine from the Russian Observational CHOICE-2 Study

INTRODUCTION

The guidelines recommend a beta-blocker or calcium channel blocker as the first-line medication for angina, supplemented by other agents for additional symptoms. One such agent is trimetazidine (TMZ), which has been shown to reduce the frequency of anginal episodes and improve exercise performance without affecting haemodynamic parameters. However, extensive real-world evidence for its efficacy in combination with first-line therapies has been lacking.

METHODS

The aim of this large-scale, Russian, multicentre, 6-month, open-label, prospective observational study was to assess the effect of adding TMZ modified release 35 mg bid to background antianginal therapy in the real-world clinical setting.

RESULTS

The study included 896 patients: 54% women, aged 29-90 years (42.6% >65 years), 63% with class II angina, and receiving beta-blockers alone or in combination (93%). Add-on TMZ reduced angina frequency and short-acting nitrate use within 2 weeks (both p < 0.0001) regardless of background therapy and maintained this effect over 6 months. It increased the proportion of patients with class I angina sixfold while decreasing that of class 3 angina almost fourfold. It also improved walking distance and well-being at 6 months (both p < 0.0001). Treatment was well tolerated.

CONCLUSION

Add-on TMZ is a safe and rapidly effective treatment for reducing angina attacks and nitrate use in the real-world clinical setting. It also increases exercise capacity and well-being. These effects are observed within 2 weeks and persist for at least 6 months.

Revascularization with percutaneous coronary intervention does not affect androgen status in males with chronic stable angina pectoris

There is a clear association between low serum testosterone and coronary artery disease (CAD) in men. Hypotestosteronaemia is associated with accelerated atherosclerosis and a quarter of men with CAD are biochemically hypogonadal. Amongst those with CAD, hypotestosteronaemia is associated with increased mortality. Testosterone vasodilates coronary arteries, and exogenous testosterone reduces ischaemia. Whether hypotestosteronaemia is a cause or a consequence of CAD remains unanswered. The aim of this prospective observational study was to investigate whether coronary revascularization affected androgen status in men with stable angina pectoris. Twenty five men (mean age 62.7, SD 9.18) with angiographically significant CAD and symptomatic angina underwent full coronary revascularization by percutaneous coronary intervention. Androgen status and symptoms of angina, stress, depression and sexual function were assessed before, and at one and 6 months after the coronary revascularization. All patients underwent complete revascularization which was associated with a significant reduction in angina symptoms and ischaemia. No significant difference was seen in total testosterone (11.33 nmol/L baseline; 12.56, 1 month post; 13.04 at 6 months; p = 0.08). A significant and sustained rise in sex hormone-binding globulin was seen (33.99 nm/L baseline; 36.11 nm/L 1 month post PCI; 37.94 nm/L at 6 months; p = 0.03) Overall, there was no significant alteration in any other marker of androgen status including free testosterone or bioavailable testosterone. There was no change in symptoms of anxiety, depression or sexual function. Coronary revascularization has no sustained effect on androgen status. This supports the hypothesis that hypotestosteronaemia is not a consequence of angina pectoris or myocardial ischaemia.

Predictors of subjective health status 10 years post-PCI

Background

Subjective health status is an increasingly important parameter to assess the effect of percutaneous coronary intervention (PCI) in clinical practice.

Aim of this study was to determine medical and psychosocial predictors of poor subjective health status over a 10 years' post-PCI period.

Methods

We included a series of consecutive PCI patients (n = 573) as part of the RESEARCH registry, a Dutch single-center retrospective cohort study.

Results

These patients completed the 36-item Short-Form Health Survey (SF-36) at baseline and 10 years post-PCI. We found 6 predictors of poor subjective health status 10 years post-PCI: SF-36 at baseline, age, previous PCI, obesity, acute myocardial infarction as indication for PCI, and diabetes mellitus (arranged from most to least numbers of sub domains).

Conclusions

SF-36 scores at baseline, age, and previous PCI were significant predictors of subjective health status 10 years post-PCI. Specifically, the SF-36 score at baseline was an important predictor. Thus assessment of subjective health status at baseline is useful as an indicator to predict long-term subjective health status. Subjective health status becomes better by optimal medical treatment, cardiac rehabilitation and psychosocial support. This is the first study determining predictors of subjective health status 10 years post-PCI.

Relationship between stent type and quality of life after percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Drug-eluting stents (DES) reduce restenosis, as compared with bare-metal stents (BMS); however, the relationship between stent type and health status is unknown. We examined whether stent type was associated with health status outcomes in patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

We evaluated 6- and 12-month health status in 2,694 patients with acute myocardial infarction (AMI) enrolled in the TRIUMPH and PREMIER registries who underwent PCI with DES (n = 1,361) or BMS (n = 1,333). Health status was assessed with the Seattle Angina Questionnaire, Medical Outcomes Study Short Form-12, and Patient Health Questionnaire depression scale. Propensity matching was performed to account for baseline differences in patient characteristics, resulting in a comparison cohort of 784 patients treated with DES and 784 patients treated with BMS. Both groups experienced significant improvements in health status at 6 and 12 months after PCI. Drug-eluting stent use was associated with a small improvement in Seattle Angina Questionnaire quality of life and functional limitation scores at 6 months (3.6 [95% CI 0.96-6.21], P = .007, and 3.8 [1.55-6.01], P < .001, respectively), but not at 12 months (2.3 [-0.46 to 5.03], P = .10, and 0.3 [-2.04 to 2.48], P = .85, respectively).

CONCLUSIONS

In patients with AMI undergoing PCI, DES use was associated with transient but unsustained health status benefits over 12 months after AMI.

Comparison of Outcomes and Quality of Life between Hemodialysis and Peritoneal Dialysis Patients in Indian ESRD Population

BACKGROUND

Hemodialysis (HD) and peritoneal dialysis (PD) are important renal replacement treatments in end stage renal disease (ESRD). There is paucity of data comparing outcomes and quality of life (QOL) between the two modalities in Indian scenario.

MATERIALS AND METHODS

We followed 60 End stage renal disease patients (30 CAPD and 30 Maintenance hemodialysis) for a period of one year. Patients were analysed and compared for complications, physical quality of life and psychological well being with a two part self reported questionnaire at baseline and subsequently at six and twelve months. For the physical component appropriate sections of the McMaster Health Index Questionnaire (MHIQ) and for psychological component Psychological General Well-Being Index (PGWB) developed by Dupey was applied.

RESULTS

The number of males and females in both groups were comparable (p-value > 0.05).The prevalence of diabetes mellitus, coronary artery disease, obesity and ischaemic heart disease was comparable in both groups (p-value>0.05). Significantly higher mortality was observed in patients undergoing HD (20% vs 0 %, p-value <0.05) at the end of study. At the end of study, 16.6% of patients undergoing HD were found to be anti HCV positive as compared to 3.33% in CAPD. Six episodes of CAPD peritonitis were observed (0.2 episodes per catheter year). Significantly higher number of CAPD patients had negative responses between 2-4 at baseline and subsequently on follow ups in Part A of QOL questionnaire(86.7 vs 23.3 % at baseline, 80 vs 26.7% at 6 months, 80 vs16.7 % at 12 months; p <0.05 ). Mean score in Part B of questionnaire was significantly higher in CAPD patients at baseline and at all follow ups (66.7±11 vs 50.1±17 at baseline, 66.7±12.1 vs 53.32±16.3 at 6 months, 65.3±9.5 vs 48.8±16.7 at 12 months , p <0.05) .

CONCLUSION

CAPD patients have significantly better quality of life in physical as well as psychological aspects and have significantly lower mortality when compared with hemodialysis patients.

Use of stress testing and diagnostic catheterization after coronary stenting: association of site-level patterns with patient characteristics and outcomes in 247,052 Medicare beneficiaries

OBJECTIVES

The aim of this study was to determine diagnostic testing patterns after percutaneous coronary intervention (PCI).

BACKGROUND

Little is known about patterns of diagnostic testing after PCI in the United States or the relationship of these patterns to clinical outcomes.

METHODS

Centers for Medicare and Medicaid Services inpatient and outpatient claims were linked to National Cardiovascular Data Registry CathPCI Registry data from 2005 to 2007. Hospital quartiles of the cumulative incidence of diagnostic testing use within 12 and 24 months after PCI were compared for patient characteristics, repeat revascularization, acute myocardial infarction, and death.

RESULTS

A total of 247,052 patients underwent PCI at 656 institutions. Patient and site characteristics were similar across quartiles of testing use. There was a 9% and 20% higher adjusted risk for repeat revascularization in quartiles 3 and 4 (highest testing rate), respectively, compared with quartile 1 (lowest testing rate) (p = 0.020 and p < 0.0001, respectively). The adjusted risk for death or acute myocardial infarction did not differ among quartiles.

CONCLUSIONS

Although patient characteristics were largely independent of rates of post-PCI testing, higher testing rates were not associated with lower risk for myocardial infarction or death, but repeat revascularization was significantly higher at these sites. Additional studies should examine whether increased testing is a marker for improved quality of post-PCI care or simply increased health care utilization.

Feelings of being disabled as a prognostic factor for mortality in the drug-eluting stent era

OBJECTIVE

It remains unclear whether feelings of being disabled are a relevant psychological factor that determines outcome after percutaneous coronary intervention (PCI). Therefore, we evaluated "feelings of being disabled" as an independent risk factor for mortality 4 years post-PCI.

METHODS

As part of the Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) Registry, 658 consecutive patients (age 63 years, 75% male) completed the subscale "feelings of being disabled" of the Heart Patients Psychological Questionnaire (HPPQ), within the first month after PCI.

RESULTS

At 4-year follow-up, 8% of the patients (n=55) had died, 2% (n=16) underwent a myocardial infarction (MI), 13% (n=90) had a target-vessel revascularization (TVR), and 21% (n=137) had one or more major adverse cardiac events (MACE). One-third of the patients (32%) had high scores on "feelings of being disabled" at baseline. After adjusting for baseline characteristics, including symptoms of anxiety and depression, patients with a high score on "feelings of being disabled" had an increased risk for all cause mortality (HR=2.9, 95% CI=1.5-5.6), the composite end point mortality/MI (HR=2.4, 95% CI=1.3-4.4), and the occurrence of MACE (HR=1.7, 95% CI=1.1-2.7).

CONCLUSION

Feelings of being disabled were an independent predictor of all-cause mortality, mortality/MI, and MACE 4 years post-PCI. These patients should be identified in clinical practice, as they warrant additional treatment, e.g., of a psychosocial nature, in addition to the standard medical treatment.

Effect of PCI on quality of life in patients with stable coronary disease

BACKGROUND

It has not been clearly established whether percutaneous coronary intervention (PCI) can provide an incremental benefit in quality of life over that provided by optimal medical therapy among patients with chronic coronary artery disease.

METHODS

We randomly assigned 2287 patients with stable coronary disease to PCI plus optimal medical therapy or to optimal medical therapy alone. We assessed angina-specific health status (with the use of the Seattle Angina Questionnaire) and overall physical and mental function (with the use of the RAND 36-item health survey [RAND-36]).

RESULTS

At baseline, 22% of the patients were free of angina. At 3 months, 53% of the patients in the PCI group and 42% in the medical-therapy group were angina-free (P<0.001). Baseline mean (+/-SD) Seattle Angina Questionnaire scores (which range from 0 to 100, with higher scores indicating better health status) were 66+/-25 for physical limitations, 54+/-32 for angina stability, 69+/-26 for angina frequency, 87+/-16 for treatment satisfaction, and 51+/-25 for quality of life. By 3 months, these scores had increased in the PCI group, as compared with the medical-therapy group, to 76+/-24 versus 72+/-23 for physical limitation (P=0.004), 77+/-28 versus 73+/-27 for angina stability (P=0.002), 85+/-22 versus 80+/-23 for angina frequency (P<0.001), 92+/-12 versus 90+/-14 for treatment satisfaction (P<0.001), and 73+/-22 versus 68+/-23 for quality of life (P<0.001). In general, patients had an incremental benefit from PCI for 6 to 24 months; patients with more severe angina had a greater benefit from PCI. Similar incremental benefits from PCI were seen in some but not all RAND-36 domains. By 36 months, there was no significant difference in health status between the treatment groups.

CONCLUSIONS

Among patients with stable angina, both those treated with PCI and those treated with optimal medical therapy alone had marked improvements in health status during follow-up. The PCI group had small, but significant, incremental benefits that disappeared by 36 months. (ClinicalTrials.gov number, NCT00007657.)

DEVELOPMENT AND INNOVATION IN CARDIOVASCULAR MEDICINE

The last century has witnessed groundbreaking advances in clinical medicine across the entire diagnostic and therapeutic range, but inequities in access to these advances and innovations continue to be a major challenge to our societies.

Innovations are often initiated by "eureka" moments of discovery, but realising their full potential depend on a process of continuous incremental innovation and interaction involving complex networks. When developing systems that reward, encourage, and sustain medical advances, policy makers must recognise four important factors. First, "incremental" and "continuous" innovation is as important as "breakthrough" innovation. Second, investment across the entire innovation process is needed. Third, the ability of physicians to work across a wide range of scientific fields at "the bench and bedside" is critical to continuous innovation. And fourth, final medical advance that can result from an initial discovery may not be obvious and only occur following interaction with experts and innovations in other fields.

Anxiety enhances the detrimental effect of depressive symptoms on health status following percutaneous coronary intervention

OBJECTIVE

We examined whether anxiety has incremental value to depressive symptoms in predicting health status in patients undergoing percutaneous coronary intervention (PCI) treated in the drug-eluting stent era.

METHODS

A series of consecutive patients (n=692) undergoing PCI as part of the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital registry completed the Hospital Anxiety and Depression Scale at 6 months and the Short-Form Health Survey (SF-36) at 6 and 12 months post-PCI.

RESULTS

Of 692 patients, 471 (68.1%) had no symptoms of anxiety nor depression, 62 (9.0%) had anxiety only, 59 (8.5%) had depressive symptoms only, and 100 (14.5%) had co-occurring symptoms. There was an overall significant improvement in health status between 6 and 12 months post-PCI (P<.001); the interaction effect for time by psychological symptoms was also significant (P=.003). Generally, patients with co-occurring symptoms reported significantly poorer health status compared with the other three groups (Ps <.001). Patients with co-occurring symptomatology were also at greater risk of impaired health status on six of the eight subdomains of the SF-36 compared with the other three symptom groups, adjusting for baseline characteristics and health status at 6 months.

CONCLUSION

Patients with co-occurring symptoms of anxiety and depression reported poorer health status compared with anxious or depressed-only patients and no-symptom patients, showing that anxiety has incremental value to depressive symptoms in identifying PCI patients at risk for impaired health status treated in the drug-eluting stent era.

Determinants of health-related quality of life in patients with coronary artery disease

BACKGROUND

Health-related quality of life (HRQL) is increasingly being assessed as an outcome parameter, especially in chronic diseases such as coronary artery disease (CAD), in which the goal of treatment is not only to prolong life but also to relieve symptoms and improve function.

DESIGN

This study was carried out as a non-randomized prospective multicentre study.

METHODS

Patients (N = 432) with CAD were assessed at baseline, 1 and 3 months after treatment assignment [medication, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)]. HRQL was assessed using the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) and the Short Form 36 (SF-36). Depressive and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale. Routine clinical data including disease severity were collected.

RESULTS

The short and intermediate-term results revealed HRQL differences between PCI and CABG in the month immediately after intervention despite the almost identical reduction in angina severity over the first month in both groups. PCI was associated with a relatively rapid increase in HRQL in the first month, with little further change by 3 months. In contrast, after CABG there was an initial deterioration in HRQL, which then improved significantly. The change in depression and anxiety score uniquely accounted for most of the change in the SF-36 (6%, 64%) and MacNew scales (4%, 69%), whereas treatment accounted for less than 1% in any HRQL scale score changes.

CONCLUSIONS

There appears to be evidence suggesting that HRQL changes after treatments in patients with CAD may be more strongly influenced by mood disturbance than by treatment methods.

Prevalence and predictors of angina pectoris one month after myocardial infarction

Angina pectoris (AP) is a treatable symptom that is associated with mortality and decreased quality of life. The prevalence and predictors of AP 1 month after a myocardial infarction (MI), a time when additional treatments might be offered, have not been described. We prospectively enrolled 2,094 patients with MI from 19 centers in the United States and evaluated angina symptoms 1 month after discharge with the Seattle Angina Questionnaire. Multivariable logistic regression analysis was performed to identify patient and treatment characteristics associated with 1-month AP. At 1 month, 571 patients (27.3%) had AP. Women (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.09 to 1.74), younger patients (OR 1.33 per 10-year increment, 95% CI 1.20 to 1.47), those with previous coronary artery bypass (OR 1.47, 95% CI 1.05 to 2.05), smokers (OR 1.35, 95% CI 1.09 to 1.77), and those who developed postinfarct AP during the index hospitalization (OR 1.85, 95% CI 1.20 to 2.65) were more likely to have AP at follow-up. In contrast, patients who were treated with coronary artery bypass surgery during their index admission were less likely to have AP at 1 month (OR 0.5, 95% CI 0.33 to 0.77). The strongest correlate was the frequency of AP before patients' MI. Compared with those without AP before MI, those with AP < 1 time per week (OR 1.86, 95% CI 1.45 to 2.41), weekly (OR 4.24, 95% CI 3.09 to 5.82), and daily (OR 6.12, 95% CI 3.62 to 10.3) were more likely to have AP 1 month later. In conclusion, > 1 in 4 patients reported AP 1 month after an MI.

Risk factors for impaired health status differ in women and men treated with percutaneous coronary intervention in the drug-eluting stent era

OBJECTIVES

In patients treated with percutaneous coronary intervention (PCI) in the drug-eluting stent era, we compared women's and men's health status 6 and 12 months post-PCI and investigated whether predictors of poor health status at 12 months are similar for women and men.

METHODS

Consecutive patients (n=692; 28% women) treated with PCI completed the 36-item Short-Form Health Survey (SF-36) 6 and 12 months post-PCI.

RESULTS

There was a significant improvement in health status over time (P<.001), but women experienced a significantly poorer health status compared with men (P<.001) at 6 and 12 months, adjusting for differences in baseline characteristics and health status at 6 months. Predictors of impaired health status were generally different for women and men. In women, the predominant predictors were previous coronary artery bypass graft (CABG) surgery, renal impairment, and older age; in contrast, in men, older age was associated with better functioning. In women, previous CABG was associated with a 4-15 fold increased risk of impaired health status. Health status at 6 months was a predictor of all SF-36 domains at 12 months in both women and men.

CONCLUSIONS

Women reported poorer health status compared with men 6 and 12 months post-PCI, and predictors of impaired health status generally differed for women and men. Further studies examining risk factors for adverse outcomes for women and men separately, which will lead to better risk stratification in research and clinical practice, are warranted.

Outcomes after acute coronary syndrome admission to primary versus tertiary Veterans Affairs medical centers: the Veterans Affairs Access to Cardiology study

BACKGROUND

There is a concern that patients with acute coronary syndrome (ACS) admitted to primary care hospitals (without on-site cardiac procedures) may be at risk for worse outcomes compared with patients admitted to tertiary care hospitals. In addition to mortality, one way to assess patient outcomes is via health status and rehospitalization rates. We compared the health status and rehospitalization of patients with ACS admitted to primary versus tertiary care Veterans Affairs hospitals.

METHODS

This was a cohort study of 2132 patients with ACS admitted to 21 Veterans Affairs hospitals (12 primary care and 9 tertiary care) from 1998 to 1999. Primary outcomes were 7-month health status as measured by the Seattle Angina Questionnaire and rehospitalization. Hierarchical multivariable regression was used to evaluate the association between admission to a primary (vs tertiary) care hospital and these outcomes. Discharge medications and 7-month cardiac procedure rates were also compared.

RESULTS

There were no significant differences in discharge medication rates between primary and tertiary hospital patients. Forty-two percent of the patients admitted to a primary care hospital was transferred to a tertiary care hospital during index admission. Primary hospital patients had significantly lower 7-month rates of cardiac catheterization (36% vs 51%, P < .001) and percutaneous coronary intervention (11% vs 20%, P < .001), but there were no differences in coronary artery bypass graft surgery rates. After risk adjustment, there were no significant differences in 7-month angina frequency (odds ratio [OR] 0.98, 95% CI 0.78-1.22), physical limitation (OR 0.97, 95% CI 0.77-1.23), quality of life (OR 1.12, 95% CI 0.89-1.40), or rehospitalization (OR 1.07, 95% CI 0.54-2.14) between the 2 groups.

CONCLUSIONS

These results suggest that an integrated health care system can achieve similar intermediate-term health status and rehospitalization outcomes for patients with ACS irrespective of the site of admission despite the lower rates of cardiac procedures for the primary care hospital patients.

Changes in myocardial perfusion due to physical exercise in patients with stable coronary artery disease

PURPOSE

Percutaneous transluminal coronary angioplasty (PTCA) is one of the main therapy options for patients with coronary artery disease (CAD), resulting in an improvement in myocardial perfusion and exercise capacity. Nevertheless, studies have also demonstrated a positive effect of regular exercise training on myocardial perfusion and maximum exercise capacity. The aim of this study was to evaluate changes in myocardial stress perfusion after 1 year of exercise training in comparison with the effects of PTCA in patients with CAD.

METHODS

In 66 male patients with angiographically confirmed significant coronary artery stenosis in one target vessel, myocardial perfusion scintigraphy was performed at baseline and 12 months after randomisation into either a physical exercise group or a PTCA group. Circumferential count rate profiles in 16 wall segments were classified according to their relative count rate and localisation within or outside the area supplied by the stenosed vessel.

RESULTS

Ischaemic segments showed a significant improvement in myocardial count rate within the target area after 12 months in both the PTCA and the training group (PTCA group: from 76.8+/-4.9% to 86.6+/-10.9%, p=0.03; training group: from 74.0+/-7.3% to 83.7+/-10.8%, p<0.01). Outside the target area only the training group showed a significant improvement (from 77.7+/-4.4% to 91.7+/-4.8%, p<0.01).

CONCLUSION

Our data indicate a significant improvement in stress myocardial perfusion in the training group after 12 months. The ischaemia is reduced not only in the target region of the leading stenosis but also in other ischaemic myocardial areas. In contrast, after PTCA stress perfusion improves only in the initially ischaemic parts of the target area.

Care of elderly patients with chronic symptomatic coronary artery disease: is it TIME to be more offensive?

Young patients with coronary artery disease usually benefit from revascularization in terms of symptom relief and outcome. There are no prospective data available, however, for patients older than age 75 years, for whom quality of life might be more of an issue than quantity of life and for whom risk profiles and comorbidities make treating physicians more reluctant to prescribe an invasive procedure. The recently published Trial of Invasive vs. Medical therapy in Elderly patients (TIME) was the first to address patients > or =75 years of age with chronic angina despite standard medical therapy. The authors discuss the benefits and risks of interventional vs. medical management of chronic, symptomatic coronary artery disease in elderly patients in view of the TIME results and their clinical implications.

Evaluation of routine functional testing after percutaneous coronary intervention

Following percutaneous coronary intervention, 348 patients were randomized to either routine or selective functional testing strategies. For the primary end point of maximal exercise endurance on a treadmill at 9 months, achievement was similar in the routine and selective groups. For the secondary end points measuring functional status and quality of life, scores were also similar. There was little difference in the rates of invasive cardiac procedures for the 2 groups at 9 months.

Health-related quality of life after percutaneous coronary intervention versus coronary bypass surgery in high-risk patients with medically refractory ischemia

OBJECTIVES

We compared six-month health-related quality of life (HRQL) for high-risk patients with medically refractory ischemia randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery.

BACKGROUND

Mortality rates after PCI and CABG surgery are similar. Therefore, differences in HRQL outcomes may help in the selection of a revascularization procedure.

METHODS

Patients were enrolled in a Veterans Affairs multicenter randomized trial comparing PCI versus CABG for patients with medically refractory ischemia and one or more risk factors for adverse outcome; 389 of 423 patients (92%) alive six months after randomization completed an Short Form-36 (SF-36) health status survey. Primary outcomes were the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36. Multivariable analyses were used to evaluate whether PCI or CABG surgery was associated with better PCS or MCS scores after adjusting for over 20 baseline variables.

RESULTS

There were no significant differences in either PCS scores (38.7 vs. 37.3 for PCI and CABG, respectively; p = 0.23) or MCS scores (45.5 vs. 46.1, p = 0.58) between the treatment arms. In multivariable models, there remained no difference in HRQL for post-PCI versus post-CABG patients (for PCS, absolute difference = 0.56 +/- standard error of 1.14, p = 0.63; for MCS, absolute difference = -1.23 +/- 1.12, p = 0.27). We had 97% power to detect a four-point difference in scores, where four to seven points is a clinically important difference.

CONCLUSIONS

High-risk patients with medically refractory ischemia randomized to PCI versus CABG surgery have equivalent six-month HRQL. Therefore, HRQL concerns should not drive decision-making regarding selection of a revascularization procedure for these patients.

Outcome of elderly patients with chronic symptomatic coronary artery disease with an invasive vs optimized medical treatment strategy: one-year results of the randomized TIME trial

CONTEXT

The risk-benefit ratio of invasive vs medical management of elderly patients with symptomatic chronic coronary artery disease (CAD) is unclear. The Trial of Invasive versus Medical therapy in Elderly patients (TIME) recently showed early benefits in quality of life from invasive therapy in patients aged 75 years or older, although with a certain excess in mortality.

OBJECTIVE

To assess the long-term value of invasive vs medical management of chronic CAD in elderly adults in terms of quality of life and prevention of major adverse cardiac events.

DESIGN

One-year follow-up analysis of TIME, a prospective randomized trial with enrollment between February 1996 and November 2000.

SETTING AND PARTICIPANTS

A total of 282 patients with Canadian Cardiac Society class 2 or higher angina despite treatment with 2 or more anti-anginal drugs who survived for the first 6 months after enrollment in TIME (mean age, 80 years [range, 75-91 years]; 42% women), enrolled at 14 centers in Switzerland.

INTERVENTIONS

Participants were randomly assigned to undergo coronary angiography followed by revascularization (if feasible) (n = 140 surviving 6 months) or to receive optimized medical therapy (n = 142 surviving 6 months).

MAIN OUTCOME MEASURES

Quality of life, assessed by standardized questionnaire; major adverse cardiac events (death, nonfatal myocardial infarction, or hospitalization for acute coronary syndrome) after 1 year.

RESULTS

After 1 year, improvements in angina and quality of life persisted for both therapies compared with baseline, but the early difference favoring invasive therapy disappeared. Among invasive therapy patients, later hospitalization with revascularization was much less likely (10% vs 46%; hazard ratio [HR], 0.19; 95% confidence interval [CI], 0.11-0.32; P<.001). However, 1-year mortality (11.1% for invasive; 8.1% for medical; HR, 1.51; 95% CI, 0.72-3.16; P =.28) and death or nonfatal myocardial infarction rates (17.0% for invasive; 19.6% for medical; HR, 0.90; 95% CI, 0.53-1.53; P =.71) were not significantly different. Overall major adverse cardiac event rates were higher for medical patients after 6 months (49.3% vs 19.0% for invasive; P<.001), a difference which increased to 64.2% vs 25.5% after 12 months (P<.001).

CONCLUSIONS

In contrast with differences in early results, 1-year outcomes in elderly patients with chronic angina are similar with regard to symptoms, quality of life, and death or nonfatal infarction with invasive vs optimized medical strategies based on this intention-to-treat analysis. The invasive approach carries an early intervention risk, while medical management poses an almost 50% chance of later hospitalization and revascularization.

Effects of enhanced external counterpulsation on Health-Related Quality of Life continue 12 months after treatment: a substudy of the Multicenter Study of Enhanced External Counterpulsation

BACKGROUND

The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP) was the first prospective, randomized, blinded, sham-controlled study of enhanced external counterpulsation (EECP) in the treatment of chronic stable angina. We previously reported that EECP therapy lengthens the time to exercise-induced myocardial ischemia and reduces angina. We now describe the effects of EECP therapy versus a sham-treated control group in terms of patients' functioning, their senses of well-being and other Health-Related Quality Of Life (HQOL) parameters from baseline to end of treatment and from baseline to 12 months after treatment.

OBJECTIVE

To determine whether a 35-hour course of EECP affects the HQOL of patients with symptomatic coronary artery disease, 12 months following treatment.

METHODS

Seventy-one of the 139 patients enrolled in MUST-EECP provided evaluable patient-completed questionnaires at baseline, at the end of treatment, and 12 months post-treatment. The Medical Outcomes Study 36-Item Short-Form Health Survey and the Quality of Life Index-Cardiac Version III were used to assess effects on HQOL.

RESULTS

Both groups had similar HQOL scores at baseline. At end of treatment and at 12-month follow up, patients who had active-CP reported greater improvement than those who had inactive-CP in all nine quality of life scales, including ability to perform activities of daily living, ability to work, bodily pain, confidence in health, energy, ability to engage in social activities with family and friends, anxiety and depression, and quality of life issues from the effects of angina on health and functioning. Despite small sample sizes, active-CP patients demonstrated significantly greater improvement at 12 months following treatment in bodily pain, social functioning, and quality of life specific to cardiac patients compared with inactive-CP patients.

CONCLUSION

Significant health-related quality of life improvements were measurable up to 12 months after the completion of treatment with EECP. Improvements in this controlled study are consistent with HQOL changes reported in case series and patient registries. Larger studies are warranted.

Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial

BACKGROUND

Since previous randomised treatment trials in coronary disease have focused on patients younger than 75 years of age, their findings might not apply to the elderly population in whom the cardiac risk profile, risk of intervention, and comorbidities are increased. We aimed to assess quality of life and outcome of elderly patients with coronary disease after medical or revascularisation therapy.

METHODS

In this randomised, prospective, multicentre trial, we enrolled patients aged 75 years or older with chronic angina of at least Canadian Cardiac Society class II despite at least two antianginal drugs. Patients were randomly assigned coronary angiography and revascularisation or optimised medical therapy. The primary endpoint was quality of life after 6 months, as assessed by questionnaire and the presence of major adverse cardiac events (death, non-fatal myocardial infarction, or hospital admission for acute coronary syndrome with or without the need for revascularisation). Analysis was by intention to treat.

FINDINGS

150 patients were assigned medical therapy and 155 invasive therapy. Two protocol violators in each group were not included in the analysis. After 6 months, angina severity decreased and measures of quality of life increased in both treatment groups; however, these improvements were significantly greater after revascularisation. Major adverse cardiac events occurred in 72 (49%) of patients in the medical group and 29 (19%) in the invasive group (p<0.0001).

INTERPRETATION

Patients aged 75 years or older with angina despite standard drug therapy benefit more from revascularisation than from optimised medical therapy in terms of symptom relief and quality of life. Therefore, these patients should be offered invasive assessment despite their high risk profile followed by revascularisation if feasible.

Exercise training intervention after coronary angioplasty: the ETICA trial

OBJECTIVES

The goal of this study was to determine the effects of exercise training (ET) on functional capacity and quality of life (QOL) in patients who received percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting (CS), the effects on the restenosis rate and the outcome.

BACKGROUND

It is unknown whether ET induces beneficial effects after coronary angioplasty.

METHODS

We studied 118 consecutive patients with coronary artery disease (mean age 57+/-10 years) who underwent PTCA or CS on one (69%) or two (31%) native epicardial coronary arteries. Patients were randomized into two matched groups. Group T (n = 59) was exercised three times a week for six months at 60% of peak VO2. Group C (n = 59) was the control group.

RESULTS

Only trained patients had significant improvements in peak VO2 (26%, p < 0.001) and quality of life (26.8%, p = 0.001 vs. C). The angiographic restenosis rate was unaffected by ET (T: 29%; C: 33%, P = NS) and was not significantly different after PTCA or CS. However, residual diameter stenosis was lower in trained patients (-29.7%, p = 0.045). In patients with angiographic restenosis, thallium uptake improved only in group T (19%; p < 0.001). During the follow-up (33+/-7 months) trained patients had a significantly lower event rate than controls (11.9 vs. 32.2%, RR: 0.71, 95% confidence interval [CI]: 0.60 to 0.91, p = 0.008) and a lower rate of hospital readmission (18.6 vs. 46%, RR: 0.69, 95% CI: 0.55 to 0.93, p < 0.001).

CONCLUSIONS

Moderate ET improves functional capacity and QOL after PTCA or CS. During the follow-up, trained patients had fewer events and a lower hospital readmission rate than controls, despite an unchanged restenosis rate.

Health related quality of life after conservative or invasive treatment of inducible postinfarction ischaemia. DANAMI study group

OBJECTIVE

To assess health related quality of life in patients with inducible postinfarction ischaemia.

DESIGN

A questionnaire based follow up study on patients randomised to conservative or invasive treatment because of postinfarction ischaemia.

SETTING

Seven county hospitals in eastern Denmark and the Heart Centre, National University Hospital, Copenhagen, Denmark.

PATIENTS

113 patients with inducible postinfarction ischaemia: 51 were randomised to conservative treatment and 62 to invasive treatment. Average follow up time was three years (19-57 months).

MAIN OUTCOME MEASURES

SF-36, Rose angina and dyspnoea questionnaire, drug use, lifestyle, and cognitive function.

RESULTS

Invasively treated patients scored better on the SF-36 scales of physical functioning (p = 0.03) and on role-physical (p = 0.04) and physical component scales (p = 0.05) and took significantly less anti-ischaemic drug treatment. Angina occurred in 18% of the invasively treated patients and 31% of the conservatively treated patients (p = 0.09). However, more invasively treated patients suffered from concentration difficulties (18% v 4%; p = 0.04).

CONCLUSIONS

Patients who were treated invasively had better health related quality of life scores in the physical variables compared with conservatively treated patients. However, a larger proportion of invasively treated patients had concentration difficulties.

Association of patients' perception of health status and exercise electrocardiogram, myocardial perfusion imaging, and ventricular function measures

BACKGROUND

Patients' viewpoint of their health status is increasingly used as an important outcome measure of the success of treatments. Because clinicians rarely formally measure patients' health-related quality of life, the question arises whether noninvasive testing for ischemia can provide similar information regarding physical functioning and general health perception.

METHODS

We measured physical functioning and general health status with the Medical Outcomes Study Short Form (SF-36) survey in 195 consecutive patients (68% male, mean age 55.6 +/- 11.1 years) referred for exercise testing with myocardial perfusion imaging. The survey was completed immediately before the exercise test.

RESULTS

In the multivariate analysis, the strongest predictor of physical functioning and general health perception was metabolic equivalents. However, the best model, including demographic, clinical, and test variables, predicted only 14% of the variation in physical functioning and 10% of the variability in general health perception.

CONCLUSIONS

The variation in physical functioning and general health perception, as measured by the SF-36, among patients referred for exercise testing is not predicted well by the results of the test. As expected, several test results are significantly associated with physical functioning and general health perception; however, there was substantial overlap among individual patients, suggesting that the parameters are poor surrogates for the actual assessment of the domains. If these domains are deemed important to tracking patient outcomes, then they should supplement the current assessments of these patients.

Perceptions of benefit and risk of patients undergoing first-time elective percutaneous coronary revascularization

OBJECTIVE

To assess reasons why patients undergo elective percutaneous coronary revascularization (PCR), patient expectations of the benefits of PCR, and their understanding of the risks associated with PCR. We hypothesized that patients overestimate the benefits and underestimate the risks associated with PCR.

DESIGN

A prospective, semistructured questionnaire.

PARTICIPANTS

Patients undergoing their first elective PCR.

MAIN RESULTS

Fifty-two consecutive patients with a mean age of 64.3 years (range 39-87) completed the interview. Although 30 (57%) patients cited relief of symptoms as at least 1 reason to have PCR, 32 (62%) patients cited either an abnormal diagnostic test result (i.e., exercise stress test or catheterization) or "pathophysiologic" problem (i.e., "I have a blockage"), with 17 patients (33%) citing these reasons alone as indications for PCR. Thirty-nine (75%) patients believed PCR would prevent a future myocardial infarction, and 37 (71%) patients felt PCR would prolong their life. Regarding the potential complications, only 24 patients (46%) could recall at least 1 possible complication. However, on a Deber questionnaire, the majority of patients (67%) stated that they should determine either mostly alone or equally with a physician how acceptable the risks of the procedure are for themselves.

CONCLUSIONS

The majority of patients had unrealistic expectations about the long-term benefits of elective PCR and was not aware of the potential risks, even though they expressed a strong interest in participating in the decision to have PCR. More work is needed to define the optimal strategy to educate patients about the benefits and risks of elective PCR, and whether such education will affect patient decision making.

Percutaneous coronary intervention versus medical therapy for coronary heart disease

Medical therapy reduces myocardial infarction and death in patients with stable coronary heart disease (CHD). In contrast, there is little evidence available to evaluate the impact of percutaneous coronary intervention (PCI) on hard endpoints in such patients. Four randomized, controlled trials have compared PCI with medical therapy. These studies have demonstrated that PCI results in an improvement in angina and exercise tolerance compared with medical therapy, but they also suggest that medical therapy may be preferable to PCI with respect to the risk of cardiac events. Interpretation of these studies has been limited by small sample size, exclusion of high-risk subjects, no or reduced use of stents, lack of a cost- effectiveness evaluation, and absence of risk factor intervention (except for Atorvastatin versus Revascularization Treatment, which used aggressive low-density lipoprotein lowering with atorvastatin in the medical group only). The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial will permit better definition of the role of PCI in the treatment of stable or recently stabilized patients with CHD.

Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina

OBJECTIVES

We sought to evaluate the impact of percutaneous transluminal coronary angioplasty (PTCA) and medical treatment on self-perceived quality of life among patients with angina.

BACKGROUND

The second Randomized Intervention Treatment of Angina trial (RITA-2) implemented initial policies of PTCA or continued medical treatment in patients with angina, allowing assessment of long-term health consequences.

METHODS

A total of 1,018 patients were randomly assigned (504 to PTCA and 514 to medical treatment). The short form 36 (SF-36) self-administered quality-of-life questionnaire was completed at randomization and three months, one year and three years later. To date, 98% of patients reached one year and 67% reached three years.

RESULTS

The PTCA group had significantly greater improvements in physical functioning, vitality and general health at both three months and one year, but not at three years. These quality-of-life scores were strongly related to breathlessness, angina grade and treadmill exercise time both at baseline and at one year. The treatment differences in quality of life are explained by the PTCA group's improvements in breathlessness, angina and exercise time. The attenuation of treatment difference at three years is partly attributed to 27% of medically treated patients receiving nonrandomized interventions in the interim. For both groups, there were also improvements in ratings of physical role functioning, emotional role functioning, social functioning, pain and mental health, but for these the superiority of PTCA over medical treatment was less pronounced. After one year, 33% and 22% of the PTCA and medical groups, respectively, rated their health much better.

CONCLUSIONS

Coronary angioplasty substantially improves patient-perceived quality of life, especially physical functioning and vitality, as compared with continued medical treatment. These differences are attributed to alleviation of cardiac symptoms (specifically, breathlessness and angina), but must be balanced against the small procedure-related risks of PTCA.

Perceived health over 3 years after percutaneous coronary balloon angioplasty

The magnitude of the benefit of percutaneous transluminal coronary angioplasty (PTCA) in terms of quality of life depending on baseline and outcome clinical variables is not sufficiently understood because of the restrictive inclusion criteria of randomized clinical trials. The present study was designed to assess perceived health outcome at 3 years and its association with clinical variables after successful elective PTCA in a tertiary hospital throughout a prospective cohort study. Questionnaires were administered on the day before the procedure and 1 month and 3.4 years later (as mean follow-up) to 106 patients recruited during a 15-month period. Mean perceived health scores improved significantly for the population as a whole 1 month after PTCA, and improvement was maintained at the end of follow-up. The magnitude of the effect was different depending on clinical subgroups: (a) It was greatest in patients free from angina, myocardial infarction, or new revascularization procedures at the end of follow-up; (b) It was moderately reduced in patients with comorbidity; (c) Patients who reported to have dyspnea or angina at rest after the latest revascularization procedure did not improve, with poor final perceived health scores. Elective PTCA is associated with a significant improvement in perceived health, which varies depending on the clinical outcome. Comorbidity and initial perceived health influence outcome but do not preclude improvement.

The challenge of health care delivery to the elderly patient with cardiovascular disease. Demographic, epidemiologic, fiscal, and health policy implications

Old age as our society is experiencing it is a new phenomenon. Never before in history have societies of developed countries enjoyed such longevity of life. In the next several decades the United States will face an unparalleled increase in the absolute number of elderly persons in our population. How will health care professionals, policy-makers, and society in general face the mammoth task of providing quality cardiovascular care for the elderly in an environment of limited financial resources? This article discusses the demographic, fiscal, and health policy implications of our aging society with particular emphasis on existing and anticipated impediments to the delivery of cardiovascular care to this rapidly expanding segment of our population.

Functional status and well-being in patients with glaucoma as measured by the Medical Outcomes Study Short Form-36 questionnaire

PURPOSE

This study aimed to determine whether patients with glaucoma have different functional status and well-being than patients without glaucoma.

DESIGN

Prospective case-control study.

PARTICIPANTS

The study population was recruited from 2 university-based glaucoma clinical practices and a university-based general ophthalmology clinic and consisted of 121 patients with open-angle glaucoma, 42 with diagnosis of glaucoma suspect, and 135 with no chronic ocular conditions except cataract.

INTERVENTION

Administration of Medical Outcomes Study 36-item short-form survey (SF-36) was performed. Demographic information, medical history, and responses to the SF-36 questionnaire were elicited by an interviewer. Medical record review was performed to obtain clinical examination data and to substantiate the medical and demographic data obtained by the interviewer.

MAIN OUTCOME MEASURES

The SF-36 scores by diagnostic group, demographic characteristics, and medical history were examined. Secondary outcome measures were SF-36 scores in patients with glaucoma by visual field impairment and glaucoma medication use.

RESULTS

Patients with glaucoma consistently had lower scores, control subjects had higher scores, and glaucoma suspects had scores intermediate between the two groups. After adjusting for the possible influence of all the other covariate factors, glaucoma was found to be a strong predictor of lower SF-36 scores.

CONCLUSION

Patients with glaucoma have lower scores, indicating less-functional status, than patients without glaucoma as tested by the SF-36 survey questionnaire.

Quality of life in coronary artery disease

BACKGROUND

Coronary artery disease (CAD) constitutes a considerable financial burden on society in Finland; it is the cause of death of approximately 7,500 men and 6,500 women annually in a population of 5 million.

OBJECTIVES

The purpose of this study was to assess the changes in the quality of life (QOL) of patients with CAD treated by medication, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass surgery (CABS) during 1 year.

METHOD

The study population consisted of 280 patients with CAD. One hundred patients had been referred to CABS and another 100 to PTCA, whereas 80 patients were on drug therapy. The patients assessed their health status and QOL in terms of functional capacity and aspects of distress using self-completed questionnaires with the Nottingham Health Profile (NHP) instrument before the operation and 6and 12 months afterwards.

RESULTS

The QOL of the patients who had undergone CABS and PTCA was significantly better on the dimensions of energy, pain, and mobility 1 year after the intervention. In the medication group, the only improvement took place on the dimension of social isolation, whereas both energy and mobility deteriorated.

CONCLUSIONS

The results on QOL obtained in this study support the notion that patients continue to have many problems even after medical treatment with a good outcome. The problems occur in different areas compared with the pretreatment situation as on the dimensions of social isolation and emotional reaction. The rehabilitation of CAD patients is therefore important because the new problems are manifested differently from those seen before the illness or the treatment. The patient's QOL and personal preference for a treatment modality should be important criteria in the choice of treatment.

A population-based perspective of changes in health-related quality of life after myocardial infarction in older men and women

This study analyzes changes in health-related quality-of-life (HQL) outcomes following myocardial infarction (MI) from a population-based perspective. Data came from a representative sample of 2812 men and women 65 years and older living in New Haven, CT. All subjects were interviewed at baseline in 1982, and again in 1985 and 1988. HQL outcomes included self-rated health, depressive symptoms, and physical and social functioning. Pooled logistic regression models were used to estimate the risk for decline in HQL outcomes due to MI. Of the 203 MIs during follow-up, 111 (55%) survived until the next interview to provide post-MI data on outcomes. In bivariate analysis, MI patients were more likely than subjects without MI to show a decline in physical functioning (26.4% vs. 11.9%, P = .001) and social functioning (31.4% vs. 20.8%), P = .06). There were no differences in self-rated health (26.3% vs. 26.9%), but MI patients were less likely to show an increase in depression (9.1%) vs. 15.8%, P = .08). These associations remained mostly unchanged after adjustment for CHD risk factors. The effect of MI on physical and social functioning was much stronger among patients with a recent MI (<1 year ago) than those whose MI had occurred more than a year before post-MI assessment. While a substantial proportion of MI patients experience a significant decline in quality of life-related outcomes, only some of these declines occur more frequently among MI patients than in the population at large. This effect may also be limited to the immediate post-MI period. Results from this analysis are discussed in terms of the "burden of illness" within a defined population due to MI.

Percutaneous transluminal coronary angioplasty (PTCA) without on-site surgical facilities

BACKGROUND

Numerous publications from European and Canadian centres have documented the feasibility of performing percutaneous transluminal coronary angioplasty (PTCA) without on-site surgical facilities. The absolute need for surgical standby has been changing especially with the introduction of coronary stent for bailout situations. This practice may be applicable in Australian centres especially in the environment of long waiting lists and cost containment.

AIM

To review the safety of performing PTCA by experienced operators in two Melbourne hospitals without on-site surgical facilities.

METHODS

We reviewed data of all patients who had PTCA electively (with low and moderate risks) between July 1996 and January 1997 and in the setting of acute myocardial infarction (AMI) from January 1996 to January 1997. Surgical standby was available as 'next available room' basis in nearby centres. Immediate outcome before discharge was documented and follow up from three to six months in 80% of all surviving patients.

RESULTS

There were 46 elective PTCA and 41 PTCA for AMI. PTCA was successful in 82 (94%) patients. Among the elective cases, seven patients were already inpatients with unstable or postinfarct angina. Thirteen patients had stents deployed with three for acute closure. Abciximab (Reopro) was given to eight patients. Two patients had acute closure in the laboratory which could not be reopened, but did not require emergency coronary artery bypass grafting (CABG). There were four inhospital deaths (three related to AMI and one died of a noncoronary cause).

CONCLUSION

PTCA can be performed electively in a selected group of patients with coronary artery disease and as a primary procedure for AMI without on-site surgical standby.