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CLARIFY: Angina in prior MI, stable CAD confers poor prognosis
PARIS — Among a cohort of patients with stable CAD, angina yielded worse outcomes in patients with prior MI but did not make a difference in patients without prior MI, according to results from the CLARIFY registry presented at the European Society of Cardiology Congress.
The researchers analyzed 32,703 patients (mean age, 64 years; 78% men) from 45 countries with chronic coronary syndrome as defined in accordance with a new ESC guideline, who were followed up for 5 years. The findings were simultaneously published in the European Heart Journal.
Chronic coronary syndrome was defined as MI at least 3 months before enrollment, revascularization at least 3 months before enrollment, symptomatic myocardial ischemia or angiographic coronary stenosis greater than 50%, Emmanuel Sorbets, MD, cardiologist at Assistance Publique-Hopitaux de Paris, Hopital Avicenne, Bobigny, France, said during a press conference.
“Previously, stable CAD and stable angina were synonyms, but we understand now that it is more complicated,” Sorbets said during a press conference. “Actually, stable CAD is a mix of several conditions. That is why we use now the term chronic coronary syndromes.”
The primary outcome of CV death or nonfatal MI occurred in 8% (95% CI, 7.7-8.3) of the overall cohort (men, 8.1%; 95% CI, 7.8-8.5; women, 7.6%; 95% CI, 7-8.3; P = .26), Sorbets said during the press conference.
When the researchers constructed a Cox proportional hazards model, they found the most prominent predictors of the primary outcome were prior HF hospitalization, current smoking, atrial fibrillation, residence in Central America or South America, prior MI, prior stroke, diabetes, current angina and peripheral artery disease (P < .001 for all).
Angina conferred a poor prognosis only if the patients also had prior MI (P for interaction = .0016), Sorbets said. In patients with prior MI, the rate of the primary outcome was 11.8% in those with angina and 8.2% in those without angina (P < .001), whereas in patients without prior MI, the rate of the primary outcome was 6.3% in those with angina and 6.4% in those without angina (P = .996), he said.
“In this largest cohort of chronic coronary syndromes followed for 5 years, patients did extremely well, with low event rates of cardiovascular death or nonfatal MI, with a rate of 1.7% per year,” Sorbets said at the press conference. “Importantly, we found that angina was correlated with worse prognosis only in patients with prior MI, and was not associated with poor prognosis in patients without prior MI. This is new, and this is why these patients need more attention.”
Use of guideline-based medical therapies was high, as 95.2% of patients were taking antiplatelet agents, 82.9% were taking statins, 75.3% were taking beta-blockers and 76.3% were taking renin-angiotensin system inhibitors, according to the researchers.
“But this high rate of medication didn’t translate necessarily into an achievement of the recommended targets in a large majority of patients,” Sorbets told Healio. “When considering conventional recommended targets available at enrollment, the rate of a blood pressure < 140/90 mm Hg was 64% and of LDL < 100 mg/dL was 60%. When considering both, only 42% reached the targets.
“A potential explanation for the mismatch between treatment and attaining targets is that full doses may not be prescribed,” Sorbets said in a press release. “A previous analysis of CLARIFY showed that just 13.3% of patients received the full dose of beta-blockers. We did not collect dose information on the other therapies. Another likely possibility is that patients did not strictly take their pills.” – by Erik Swain
References:
Sorbets E, et al. Hot Line Session 5. Presented at: European Society of Cardiology Congress; Aug. 31-Sept. 4, 2019; Paris.
Sorbets E, et al. Eur Heart J. 2019;doi:10.1093/eurheartj/ehz660.
Disclosures: The CLARIFY registry was sponsored by Servier. Sorbets reports he received fees and nonfinancial support from AstraZeneca, Bayer, Bristol-Myers Squibb, Merck Sharpe & Dohme, Novartis and Servier.
Perspective
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Results from the CLARIFY registry help characterize the increasingly heterogeneous population of those with chronic ischemic heart disease. This group may encompass those with or without angina, who have received revascularization or are being medically managed, and those with or without a history of MI. The CLARIFY registry hones in on the population of those with ischemic heart disease with a history of prior MI. This population has higher adverse event rates over a 5-year follow-up and may lend itself to more scrutiny and intensive treatment. In clinical practice, we may hone in on this population and aim to intensify their treatment.
Another interesting finding was that comorbidities such as PAD and AF were independent and robust predictors of adverse outcomes. As the authors discuss, these comorbidities may be more than associations, but important targets for treatment to assuage the morbidity and mortality associated with ischemic heart disease.
The best treatments for ischemic heart disease in those with angina and previous MI are likely a constellation of guideline-directed medical therapy, lifestyle modifications and intense scrutiny to monitor adherence and response to therapy. This population should also be considered for revascularization, as clinically appropriate. CLARIFY doesn’t suggest the need for any changes in medical treatment necessarily for this population, but draws the need for intense management in this particular population.