Impact of Angiography-Derived Physiological Patterns of CAD and Optimal Hemodynamics Post-PCI on Residual Angina.

BACKGROUND:The pullback pressure gradient (PPG) is a novel physiological metric that quantifies coronary artery disease patterns as focal or diffuse on a scale from 0 to 1. This study assessed the relationship between PPG and residual angina at 1 year.METHODS:PPG Global is a prospective, investigator-initiated, single-arm, multicenter study that enrolled patients with at least 1 lesion with a fractional flow reserve ≤0.80 intended to be treated with percutaneous coronary intervention. After the PPG calculation, physicians could revise treatment assignment to medical therapy or coronary artery bypass graft surgery instead of percutaneous coronary intervention. Focal and diffuse disease were defined based on the median PPG value of 0.62. Patient-reported outcomes were assessed using the Seattle Angina Questionnaire at baseline and 1-year follow-up.RESULTS:The study included 947 patients with PPG and the Seattle Angina Questionnaire at 1 year. The mean age was 67.6±10.2 years, 24% were female, and 29% had diabetes. At 1 year, patients with focal coronary artery disease reported less angina than those with diffuse disease (Seattle Angina Questionnaire angina frequency score, 95.3±9.9 versus 92.5±15.0; P=0.006). PPG was independently associated with improvement in angina (P=0.017).CONCLUSIONS:In patients with flow-limiting coronary artery disease, a focal disease pattern defined by high PPG was associated with greater symptomatic relief at 1 year compared with diffuse disease (low PPG). By capturing the underlying pathophysiologic distribution of epicardial disease and its relation to post-treatment symptom relief, PPG may support a more tailored revascularization decision-making and percutaneous coronary intervention strategy.

Original Article--Value of Pathological Q Waves and Angiographic Collateral Grade in Patients Undergoing Coronary Chronic Total Occlusion Recanalization: Cardiac Magnetic Resonance Study

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) effectively reduces angina symptoms and improves quality of life, but the frequency of new or residual angina (RA) in follow-up after CTO PCI and its relationship with titration of anti-anginal medications (AAM) has not been described. Methods: In consecutive CTO PCI patients treated at 12 centers in the OPEN CTO registry, angina symptoms were assessed 6 months after the index PCI using the Seattle Angina Questionnaire (SAQ) Angina Frequency scale (a score <100 defined new or residual angina). AAMs were recorded at discharge and 1 and 6 months after the index CTO PCI. AAM escalation was defined as an increase in the number or dosage of AAMs between discharge and 6-month follow-up. The proportion of patients who had escalation of AAM by 6-month follow-up was compared among those with and without 6-month angina, and analyses were repeated after stratification by the ultimate technical success of their CTO PCI (including follow-up procedures), achievement of physiologically complete revascularization during the index procedure, and presence or absence of angina at baseline. Results: Of 901 patients undergoing CTO PCI, 197 (21.9%) reported angina at 6-months. Of patients with RA, 54 (27.4%) had de-escalation, 118 (59.9%) had no change, and 25 (12.7%) had escalation of their AAM by 6 month follow-up. Although patients with residual angina were more likely to have escalation of AAMs, only 12.7% of patients with residual angina had escalation of their AAM regimens in follow-up. Results were similar when stratifying patients by the ultimate success of the CTO PCI, completeness of physiologic revascularization, and presence or absence of angina at baseline (Figure). Conclusions: One in 5 patients reported angina 6-months after CTO PCI. Although patients with new or residual angina were more likely to have escalation of AAMs in follow-up compared to those without residual symptoms, only one in 7 patients with residual angina had escalation of AAMs. These results were similar in key subgroups. Although it is unclear whether this finding reflects maximal tolerated therapy at baseline or therapeutic inertia, these findings suggest an important potential opportunity to further improve symptom control in complex stable ischemic heart disease.

Background: Relief of angina and improvement in quality of life is the most common indication for percutaneous coronary intervention (PCI) in stable ischemic heart disease (SIHD). Given that there are alternative strategies for treating angina, (e.g. intensifying optimal medical therapy (OMT) or PCI), predicting angina severity as a function of alternative treatment options can serve as a foundation for shared decision-making and the elicitation of patients’ preferences. Methods: Using data from the 2,287 SIHD patients in COURAGE trial, where PCI was randomized, we built multivariable linear regression models of Seattle Angina Questionnaire (SAQ)-assessed angina, physical function and quality of life at 6 and 12 months, using baseline SAQ scores, treatment, and all demographic and clinical characteristics available at the time of randomization. Results: At baseline, there were no significant differences between PCI and OMT groups for any SAQ domain. The strongest predictors of 6- and 12-month SAQ scores were patients’ baseline scores. Different characteristics had different degrees of association with angina, physical function and quality of life domains, with PCI being associated with 1.9-5.3-point greater improvement in SAQ scores, depending upon the domain and time frame. The adjusted R 2 of final models varied from 0.38-0.62. The results (regression coefficients with standard errors and adjusted R 2 ) of patients characteristics associated with SAQ scores for 6-month and 1-year are presented in table. Conclusions: Prediction models can be created to estimate patient-centered health status outcomes and could be used as an evidence-based foundation for supporting shared medical decision-making in SIHD. The impact of such models on treatment decisions needs to be assessed in future studies. Patient Characteristics associated with Seattle Angina Questionnaire Scores 1 Domain Time Frame Physical limitation Angina Frequency Quality of Life Factor β(SE) Factor β(SE) Factor β(SE) 6-month SAQ scores Baseline Score * Age(<65) * Gender(F) PreviousPCI E-F 3 Hypertension * MI * PCI * Diabetes * 0.51(0.02) 5.21(1.10) -1.32(1.56) -0.10(1.45) 0.15(1.40) 2.87(1.08) 2.87(1.15) 5.07(1.01) 5.22(1.14) Baseline Score * Age(<65) Gender(F) PreviousPCI E-F 3 Hypertension MI PCI * diabetes 0.28(0.02) 1.09(1.09) 0.43(1.48) 2.14(1.71) 0.98(1.42) -0.28(1.14) 1.49(1.14) 4.75(1.02) 1.56(1.11) Baseline Score * Age(<65) Gender(F) PreviousPCI E-F 3 Hypertension MI PCI * Diabetes * 0.36(0.02) -0.40(1.13) 1.12(1.53) 2.69(1.62) 1.64(1.48) -0.20(1.16) 1.95(1.19) 5.30(1.07)3.13(1.16) Adjusted R 2 0.62 Adjusted R 2 0.43 Adjusted R 2 0.42 1-year SAQ scores Baseline Score * Age(<65) * Gender(F) PreviousPCI E-F 3 Hypertension * MI PCI Diabetes * 0.46(0.03) 3.91(1.17) -0.34(1.62) 1.10(1.66) 2.21(1.57) 3.14(1.16) 2.02(1.21) 1.88(1.11) 4.64(1.22) Baseline Score * Age(<65) * Gender(F) PreviousPCI E-F 3 Hypertension MI PCI * Diabetes * 0.26(0.02) 2.12(1.05) -0.54(1.48) 0.15(1.61) 1.06(1.35) 0.51(1.11) 0.84(1.118) 3.65(0.98) 4.29(1.11) Baseline Score * Age(<65) Gender(F) PreviousPCI E-F 3 Hypertension MI PCI * Diabetes * 0.29(0.02) -1.85(1.11) 0.06(1.58) 0.94(1.65) 0.75(1.53) 0.39(1.16) 1.59(1.18) 3.12(1.08) 2.81(1.19) Adjusted R 2 0.48 Adjusted R 2 0.38 Adjusted R 2 0.41 1 Scale: 0-100; * With p <0.05; . 2 E-F: Ejection Fraction; 3 MI: Myocardial Infarction.

The frequency of residual angina and its impact on health status and death following anatomic complete revascularization in symptomatic patients with chronic coronary disease are unknown. Data were analyzed from ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial participants randomized to invasive management with baseline angina (Seattle Angina Questionnaire Angina Frequency score <100), no prior coronary artery bypass graft surgery, and anatomic complete revascularization within 90 days of randomization. The primary outcome was frequency of residual angina after revascularization, defined as a Seattle Angina Questionnaire Angina Frequency score <100 within 6 months of randomization. Secondary outcomes included 6-month health status and medication use and 5-year all-cause and cardiovascular death. Among 2588 participants randomized to invasive management, 1442 (56%) had baseline angina and no prior coronary artery bypass graft surgery; 1034 underwent revascularization within 90 days, and 436 achieved anatomic complete revascularization. Of these, 184 (42.2%) had residual angina within 6 months. Baseline characteristics were similar between those with and without residual angina. Percutaneous coronary intervention was more common than coronary artery bypass graft surgery in those with residual angina (88% versus 80%, P=0.03). At 6 months, residual angina participants reported lower quality of life (Seattle Angina Questionnaire Quality of Life: 70±20 versus 83±20, P<0.001), greater physical limitation (Seattle Angina Questionnaire Physical Limitation: 84±20 versus 95±11, P<0.001), more dyspnea (Rose Dyspnea Scale score: 1±1.3 versus 0.4±0.8, P<0.001), and more antianginal medication use (P=0.006). Five-year all-cause and cardiovascular death did not differ significantly between groups. Residual angina is common (>40%) following anatomic complete revascularization for chronic coronary disease and is associated with reduced quality of life and greater antianginal medication use but no increase in death. Unique Identifier: NCT01471522.

Correlation of Seattle Angina Questionnaire score and post-procedural outcomes in patients undergoing multi-vessel coronary intervention

Angina symptoms have been reported to predict mortality in men. The aim of this study was to investigate the association between angina symptoms and mortality in women. In 2004, 873 older participants in the Australian Longitudinal Study on Women's Health with self-reported ischemic heart disease participated in a nested substudy. Women were 77 to 83 years of age; 165 (19%) died during the 4.5-year follow-up. Angina symptoms were established with Seattle Angina Questionnaire (SAQ) scores for physical limitation, angina frequency, angina stability, and disease perception. Proportional hazards modeling was used to examine the relationship of SAQ score differences with mortality. Physical limitation scores were associated with mortality, with hazard ratios of 1.1, 1.9, and 3.4 for mild, moderate, and severe versus minimal limitations, respectively (P<0.001). Angina frequency scores were also associated with death, with hazard ratios of 1.2, 1.2, and 4.8 for mild, moderate, and severe versus minimal angina frequency, respectively (P<0.001). Age (hazard ratio 1.1, 95% confidence interval 1.0 to 1.2), pulmonary disease (hazard ratio 1.6, 95% confidence interval 1.2 to 2.3), and kidney disease (hazard ratio 1.7, 95% confidence interval 1.1 to 2.5) were statistically significantly associated with mortality in a multivariable model of clinical predictors. In a combined model with SAQ scores and clinical predictors, SAQ scores for physical limitation and angina stability remained statistically significantly associated with mortality. In older women with ischemic heart disease, angina symptoms assessed by use of SAQ scores for physical limitations and angina frequency were associated with mortality; SAQ scores may therefore prove to be a useful tool for risk assessment in this patient group.

Background: Percutaneous coronary intervention (PCI) plus intensive pharmacologic and lifestyle intervention (optimal medical therapy, OMT) to OMT alone was compared in reducing the risk of cardiovascular events in a total of 2,287 patients with stable coronary disease in the COURAGE trial, in which health related quality of life data were measured repeatedly over time for a median of 4.6 years. We examined components of changes in angina-related quality of life over time. Methods: Angina-specific health status was assessed with the Seattle Angina Questionnaire (SAQ). Scores range from 0 to 100; higher scores indicate better health status. Linear piece-wise latent growth curve modeling was conducted to reveal the components of process and risk factors of SAQ score changes over time. Results: For each domain the change process can be divided into two components: a process of improvement from baseline to 6 or 12 months during which the scores significantly increase with a steep upward trajectory till reaching the maximum score value; and followed by a process of stabilization during which the scores kept stable or in a downward slope until the end of the follow-up. Patients in both PCI and OMT alone groups experienced significant increase on SAQ scores over time in each domain. PCI had significant impact in the process of improvement: patients with PCI had about 0.603 (SE=0.193, p-value=0.002) and 0.442(SE=0.22, p-value =0.044) points increase per month in scores in the domains of physical limitation and angina frequency, respectively; the benefit of PCI decreased in the process of stabilization until it disappeared so that the scores in both groups were eventually similar (Table 1). The important risk factors of change in SAQ scores were the use of long-acting nitrates at randomization, the Charlson comorbidity index, and several additional factors that differed by domain. Conclusions: Mechanism and processes of change in angina-related quality of life and health status were significantly related to the impact of adding PCI to OMT. Piece-wise growth curve modeling can be used to capture advantages of PCI over OMT and identify patient characteristics associated with subsequent measures of angina.

Surgical collateralization: The hidden mechanism for improving prognosis in chronic coronary syndromes

Background: The COURAGE trial randomized 2,287 patients to percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) or OMT alone. We hypothesized that patients with diabetes would have lower quality of life (QOL) at baseline and benefit less from PCI than patients without diabetes. Methods: Angina frequency and QOL were assessed with the Seattle Angina Questionnaire (SAQ) at baseline, 1, 2, and 3 years. Diabetes and treatment group differences were assessed by analysis of variance and linear mixed effects models. Results: (See Table .) Diabetes status could be determined in 2,234 patients. Of these, 766 (34%) had diabetes. There were no significant baseline differences in SAQ scores for angina frequency and QOL for patients with and without diabetes. All patients experienced significant (p&lt;0.001) improvement in these SAQ scores from baseline through 3 years post-randomization in both treatment arms, however patients without diabetes had significantly greater improvement (p&lt;0.001 for both scores). The addition of PCI to OMT produced a small but statistically significant advantage for patients without diabetes that persisted for 2 years for angina frequency and 1 year for QOL; a similar advantage for PCI was observed for patients with diabetes, but this was not statistically significant, due in part to the smaller sample size. Comparison of SAQ Scores by Diabetes Status and Treatment Conclusions: COURAGE patients with and without diabetes had similar baseline angina frequency and QOL, and experienced marked improvement in these parameters in both treatment groups. Diabetic patients had less improvement in these health status scores than non-diabetic patients. The addition of PCI to OMT produced a small incremental benefit compared with OMT alone that lasted for 1–2 years, after which there were no between-group differences for patients with or without diabetes.

The psychometric properties of four quality of life instruments used in cardiovascular populations.

As stated in American College of Cardiology/American Heart Association Guidelines, randomized trials have not demonstrated that elective percutaneous coronary intervention (PCI) reduces myocardial infarction (MI) or mortality over medical treatment. Even the Fractional Flow Reserve Guided PCI Versus Medical Therapy in Stable Coronary Disease (FAME 2) trial showed no statistically significant benefit of PCI over the deferred group by traditional intention-to-treat, nonbenchmark analysis starting at randomization that includes procedure-related events. Benchmark analysis in FAME 2 beginning 1 week after PCI removed procedure-related events that counterbalanced subsequent reduced MI and mortality compared with the deferred group. Meta-analysis of the literature on risk of events related to fractional flow reserve (FFR), including FFR Versus Angiography in Multivessel Evaluation (FAME), and other physiological measures of severity reveal an underappreciated, powerful interdependence among physiological severity of stenosis, diffuse coronary artery disease (CAD), event rates, sample size, and statistical certainty of differences. This analytic review synthesizes an evidenced-based, quantitative hypothesis and potential solution to this issue based on hard data from the literature by coauthors of diverse cardiovascular disciplines in trial design, biostatistics, invasive procedures, coronary physiology, fluid dynamics, coronary pathology, and quantitative imaging. Our synthesis elucidates a dual hypothesis for failure of elective PCI in stable CAD to reduce MI or mortality and novel trial design for selecting patients for whom PCI will likely reduce these events. First, a large burden of global diffuse CAD carries a high risk of coronary events unmitigated by PCI of a focal stenosis. Second, focal stenosis severity in previous randomized revascularization trials has been too modest without objectively quantified sufficient severity to observe benefit of PCI. In previous trials, mixture of diffuse coronary disease and intermediate stenosis may not incur high enough risk for potential benefit by PCI for sample size of reported trials. Greater quantitative severity with …

BackgroundAlthough the role of percutaneous coronary intervention (PCI) as an initial strategy in the management of chronic coronary syndrome (CCS) remains debatable, the current evidence recommends intensive medical treatment as first-line therapy, with PCI reserved for those who remain symptomatic.PurposeThis study evaluated the midterm (up to 6 months) outcomes of PCI versus optimal medical therapy (OMT) alone in patients with CCS.Materials and methodsTwo hundred ten patients with CCS and >70% lesion involving one or more coronary arteries were equally randomized (1:1) to one of two groups: 105 patients underwent PCI with OMT and 105 patients were assigned to OMT alone. All patients were followed up for 6 months for the occurrence of major adverse cardiac events and the improvement in symptoms and exercise capacity.ResultsThere was no statistically significant difference between PCI and medical-therapy regarding the primary end point after 6 months of follow-up. Both groups showed improvement in anginal symptoms, although greater improvement was observed in the PCI group (P < .001). The increment of distance in a 6-minute walk test in the two groups was significant, which is higher in the PCI group (P < .001). The improvement in Seattle Angina Questionnaire score and the improvement in quality of life (assessed by the EQ-5D-5L score) in the two groups were statistically significant, which are higher in the PCI group (P < .001 for each).ConclusionPCI had no added prognostic value over OMT in patients with CCS. However, the ability of PCI to improve symptoms was more rapid and more effective than OMT.

ObjectiveTo investigate the therapeutic effects of Eight Trigrams Boxing combined with a Wenyang Huoxue recipe on the cardiopulmonary motor function and quality of life in patients with coronary heart disease after an interventional operation (percutaneous coronary intervention [PCI]); further, to provide new clinical evidence and ideas for integrated traditional Chinese and Western medicine in cardiac rehabilitation.MethodsSixty patients were selected and successfully underwent PCI in designated hospitals after four weeks, from June 2018 to September 2020. The patients were randomly divided into a treatment group and control group, and both groups were given standard pharmaceuticals after PCI and the Wenyang Huoxue recipe. The treatment group was additionally treated with the Eight Trigrams Boxing Method. The control group was provided with aerobic rehabilitation exercise. The maximum oxygen uptake (VO2max), metabolic equivalent (MET), the results of a 6-min walking test, the Seattle Angina Questionnaire (SAQ) score, SF-36 score, and other indicators were evaluated before and after treatment. The therapeutic effect was evaluated by comparison between the groups and within the groups.ResultsThe VO2max, MET, 6-min walking distance, SAQ score, and SF-36 score in both groups improved after treatment compared with before treatment. There was no difference between the two groups before treatment. However, after treatment, the VO2max, MET, 6 min walking distance, SAQ score, and SF-36 score in the treatment group were higher compared with the control group.ConclusionA traditional Chinese medicine cardiac rehabilitation program of Eight Trigrams Boxing combined with a Wenyang Huoxue recipe can improve the cardiopulmonary function and quality of life of patients. The therapeutic effect was clear and is worthy of further investigation.

See Article by Sajobi et al When I get diagnosed with obstructive coronary disease, and face a decision about whether to be treated medically, surgically, or percutaneously, I will want to know how I am likely to do—what my symptoms, function, and quality of life will be—with each treatment. I do not want to know the mean differences reported from clinical trials in which I would have likely been excluded, nor do I want to know what the guidelines say. What I want to know is how patients like me did, particularly with respect to their health status recovery, with each treatment. Only then will I have the information I need to make an informed decision as to whether the benefits of treatment warrant the risks. This vision, first articulated by Paul Ellwood 40 years ago in his 1988 Shattuck lecture,1 through the current era of funding by the Patient-Centered Outcomes Research Institute,2 has been at the forefront of my research interests. Early in the course of my career I worked to develop the means to quantify the health status of patients with coronary disease by developing the Seattle Angina Questionnaire.3 …