The effects of implementation of guideline-directed medical therapy on relief of angina in patients with stable coronary artery disease in Serbia
Ivan IlićIvan StankovićAleksandra JanićijevićJovana KušićRadosav VidakovićPetar OtaševićV. AndricSnezana PoznanovicIvana PetrovićIvana BurazorArsen RistićStevan IlićDragan BencGoran DavidovićGabrijela StojkovićBiljana PutnikovićAleksandar Nešković
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Introduction. Adherence to proposed lifestyle changes and prescribed medication in patients with stable coronary artery disease (SCAD) is poor. Objective. We sought to investigate the influence of adjusting guideline proposed medications on relief of angina in a large group of patients with SCAD in Serbia. Methods. The study included a total of 3,490 patients from 15 cardiology clinics with symptoms of stable angina and at least one of the following criteria: abnormal electrocardiogram (ECG), history of myocardial infarction (MI), positive stress test, significant coronary artery disease on coronary angiogram or previous revascularization. All the patients underwent comprehensive evaluation at initial visit and after two months. The relief of angina was study end-point defined as any reduction in Canadian Cardiology Society (CCS) class, number of angina attacks per week and/or number of tablets of short-acting nitrates per week. Results. Most patients were included based on abnormal ECG (48.4%). At Visit 1, the average number of prescribed classes of medications to a single patient increased from 4.16 ? 1.29 to 4.63 ? 1.57 (p < 0.001). At the follow-up, the patients had significantly lower blood pressure (141 ? 19 / 85 ? 11 vs. 130 ? 12 / 80 ? 8 mmHg; p < 0.001) and most of them reported CCS class I (63.3%). The average weekly number of angina attacks was reduced from 2.82 ? 2.50 at Visit 1 to 1.72 0 ? 1.66 at Visit 2, as well as average weekly use of short-acting nitrates to treat these attacks (2.69 ? 2.53 to 1.74 ? 1.47 tablets; p < 0.001 for all). Conclusion. Adjustment of prescribed medications to guideline recommendations in a large Serbian patient population with prevalent risk factors led to significant relief of angina.Keywords:
Canadian Cardiovascular Society
Guideline
Unstable angina
Coronary angiogram
Background: The Canadian Cardiovascular Society (CCS) classification system for angina is a critical determinant of revascularization appropriateness. A major limitation of CCS is that it rates patients’ symptoms from the perspective of providers, rather than patients themselves. Accordingly, we sought to evaluate the correlation of physician-assigned CCS class with patient-reported Seattle Angina Questionnaire (SAQ), before and after revascularization. Methods: Using data from the FREEDOM trial, which randomized 1900 patients from over 160 international sites to either PCI or CABG, CCS was reported by physicians and the SAQ was completed by patients prior to randomization and 1 year later. SAQ angina frequency (SAQ AF) scores were considered to correspond to CCS class per the following: SAF AF: 100=CCS 0, 61-99=CCS I, 31-60=CCS II, 0-30=CCS III/IV. Agreement between physician- and patient-reported angina categories was compared using chi square tests. Results: Among 1640 patients who had CCS and SAQ data at both baseline and 1-year, the mean age was 63.1 years, 71% were male, and 83% had 3-vessel coronary disease. Before revascularization, physicians correctly reported the burden of angina in 25.5% of patients and overestimated the burden of angina in 62.1%. Among 1194 patients who reported monthly or no angina, 229 (19.2%) were classified by their physicians as having CCS III/IV. In contrast, at follow-up, 71.2% of patients had their angina correctly estimated by their physicians and only 0.6% among the 1568 patients with monthly/no angina were assigned CCS III/IV by their physicians. Among the 28.8% misclassified by CCS at 1 year, 20.8% had less angina than reported by physicians and 8.0% had more (Figure; p=0.01). Findings were similar when the analysis was repeated in patients who were treated with PCI or CABG. Conclusions: In a large cohort of patients with stable coronary disease undergoing revascularization, clinicians often overestimated the amount of angina patients were having prior to revascularization but were significantly more accurate at follow-up. Given that importance placed on CCS for enrollment in clinical trials, or assigning appropriateness of revascularization in clinical practice, using patient-reported symptom burden as a more unbiased measure should be considered.
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Although transmyocardial laser revascularization (TMR) has provided symptomatic relief of angina over the short term, the long-term efficacy of the procedure is unknown. Angina symptoms as assessed independently by angina class and the Seattle Angina Questionnaire (SAQ) were prospectively collected up to 7 years after TMR.Seventy-eight patients with severe angina not amenable to conventional revascularization were treated with a CO(2) laser. Their mean age was 61+/-10 years at the time of treatment. Preoperatively, 66% had unstable angina, 73% had had >/=1 myocardial infarction, 93% had undergone >/=1 CABG, 42% had >/=1 PTCA, 76% were in angina class IV, and 24% were in angina class III. Their average pre-TMR angina class was 3.7+/-0.4.After an average of 5 years (and up to 7 years) of follow-up, the average angina class was significantly improved to 1.6+/-1 (P=0.0001). This was unchanged from the 1.5+/-1 average angina class at 1 year postoperatively (P=NS). There was a marked redistribution according to angina class, with 81% of the patients in class II or better, and 17% of the patients had no angina 5 years after TMR. A decrease of >/=2 angina classes was considered significant, and by this criterion, 68% of the patients had successful long-term angina relief. The angina class results were further confirmed with the SAQ; 5-year SAQ scores revealed an average improvement of 170% over the baseline results.The long-term efficacy of TMR persists for >/=5 years. TMR with CO(2) laser as sole therapy for severe disabling angina provides significant long-term angina relief.
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Background Although transmyocardial laser revascularization (TMR) has provided symptomatic relief of angina over the short term, the long-term efficacy of the procedure is unknown. Angina symptoms as assessed independently by angina class and the Seattle Angina Questionnaire (SAQ) were prospectively collected up to 7 years after TMR. Methods Seventy-eight patients with severe angina not amenable to conventional revascularization were treated with a CO 2 laser. Their mean age was 61±10 years at the time of treatment. Preoperatively, 66% had unstable angina, 73% had had ≥1 myocardial infarction, 93% had undergone ≥1 CABG, 42% had ≥1 PTCA, 76% were in angina class IV, and 24% were in angina class III. Their average pre-TMR angina class was 3.7±0.4. Results After an average of 5 years (and up to 7 years) of follow-up, the average angina class was significantly improved to 1.6±1 ( P =0.0001). This was unchanged from the 1.5±1 average angina class at 1 year postoperatively ( P =NS). There was a marked redistribution according to angina class, with 81% of the patients in class II or better, and 17% of the patients had no angina 5 years after TMR. A decrease of ≥2 angina classes was considered significant, and by this criterion, 68% of the patients had successful long-term angina relief. The angina class results were further confirmed with the SAQ; 5-year SAQ scores revealed an average improvement of 170% over the baseline results. Conclusions The long-term efficacy of TMR persists for ≥5 years. TMR with CO 2 laser as sole therapy for severe disabling angina provides significant long-term angina relief.
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Objective
To assess the long-term effect of spinal cord stimulation (SCS) on angina symptoms and quality of life in patients with refractory angina pectoris defined as severe angina due to coronary artery disease resistant to conventional pharmacological therapy and/or revascularisation.Methods
During 2003–2005, all patients with refractory angina referred for SCS treatment at 10 European centres were consecutively included in the European registry for refractory angina (European Angina Registry Link, EARL), a prospective, 3-year follow-up study. In the present study, the SCS-treated patients were followed-up regarding angina symptoms and quality of life assessed was with a generic (Short Form 36, SF-36) and a disease-specific (Seattle Angina Questionnaire, SAQ) quality of life questionnaire.Results
In total, 235 patients were included in the study. After screening, 121 patients were implanted and followed up 12.1 months after implantation. The implanted patients reported fewer angina attacks (p<0.0001), reduced short-acting nitrate consumption (p<0.0001) and improved Canadian Cardiovascular Society class (p<0.0001). Furthermore, quality of life was significantly improved in all dimensions of the SF-36 and the SAQ. Seven (5.8%) of the implanted patients died within 1 year of follow up.Conclusions
SCS treatment is associated with symptom relief and improved quality of life in patients with refractory angina pectoris suffering from severe coronary artery disease.Canadian Cardiovascular Society
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Background: In the International Enhanced External Counterpulsation Patient Registry (IEPR), approximately 85% of the patients treated are in Canadian Cardiovascular Society (CCS) class III-IV with no option for further invasive coronary revascularization procedures. Hypothesis: This study sought to determine whether it is clinically important to establish whether the observed durable reduction in disabling severe angina with enhanced external counterpulsation (EECP) treatment can be extended to those with less severe CCS class II angina, who also have no option for further revascularization. Methods: This study evaluated the immediate response, durability and clinical events over a 2-year period after EECP treatment in 112 patients with Canadian Cardiovascular Society (CCS) class II angina versus 1,346 patients with class III-IV angina using data from the International EECP Patient Registry (IEPR). Results: Treatment with EECP significantly (by at least one CCS class) reduced angina frequency, nitroglycerinuse, and improved quality of life in both groups. At 2-yearfollow-up, 74% of class II and 70% of class III-IV patients remained free of major adverse cardiovascular events (MACE) and continued to demonstrate a durable CCS class improvement over baseline. Conclusion: The robust effectiveness of EECP as a noninvasive device, together with its relatively low start-up and recurrent costs, makes it an attractive consideration for treating patients with milder refractory angina in addition to the patient with severely disabling angina treated in current practice.
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A 54-year-old lady presented with Canadian cardiovascular society class II stable angina of 6 months duration. Clinical examination and investigations were unremarkable, including normal echocardiogram. She underwent elective coronary angiogram through right radial access, which revealed double vessel disease, and was discharged 6 h after the procedure. Two months afterwards, …
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Studies of the relationship between patient self-reported angina symptoms using the Seattle Angina Questionnaire (SAQ) and angiographic findings after coronary artery bypass grafting surgery (CABG) are lacking. Nested within a randomized controlled trial, this prospective observational cohort comparison study aimed to assess which clinical characteristics and angiographic findings are associated with self-reported angina 1 year after CABG.Patients from the ROOBY trial (Randomized On/Off Bypass) with protocol-specified 1-year post-CABG coronary angiography and SAQ assessments were included (n=1258). Patients reporting no angina (62.3%) within 4 weeks before the 1-year post-CABG study visit on the SAQ angina frequency domain were compared with patients reporting angina (37.7%). Multivariable modeling identified clinical variables and angiographic findings associated with angina. Sequential univariate and multivariable modeling found the following demographic and clinical factors were associated with angina after CABG: younger age, worse preoperative SAQ angina frequency score, smoking, diabetes mellitus, and pre-CABG depression. The only 1-year angiographic finding significantly associated with angina was incomplete revascularization of the left anterior descending (LAD) territory. Graft occlusions, incomplete revascularization of non-LAD territories, and ≥70% lesions in nonrevascularized native coronary arteries were not correlated with the presence or absence of angina. Further, only 30.6% of subjects reporting angina at 1 year had a residual major coronary artery stenosis of ≥70%.Self-reported angina 1 year after CABG is associated with younger age, worse baseline SAQ angina frequency score, smoking, diabetes mellitus, and depression. The only angiographic finding associated with angina was a poorly revascularized LAD territory. These results may help guide physicians when counseling patients on expected improvements in angina symptoms and in making decisions regarding the need for coronary angiography after CABG. Whether intensive treatment of these comorbidities improves post-CABG angina symptoms requires further study.URL: https://www.clinicaltrials.gov . Unique identifier: NCT00032630.
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