Conservative management effective in patients with stable angina
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Most patients with stable CAD and anginal symptoms experienced improvement in angina over time without any changes to antianginal therapy or need for coronary revascularization, according to results from the CLARIFY registry.
“Angina affects almost one-quarter of patients with stable CAD but resolves without events or coronary revascularization in most patients,” Jules Mesnier, MD, from the Hopital Bichat in Paris, and colleagues wrote in Circulation.
The study included data on 32,691 patients with stable CAD from the prospective, observational CLARIFY registry. Researchers mapped anginal status each year among patients without new coronary revascularization or new MI, and assessed the use of medical interventions in the year preceding angina resolution. They also used multivariable analysis to determine the impact of 1-year changes in angina status on 5-year outcomes.
The composite of CV death or nonfatal MI served as the primary outcome.
In all, 22.1% patients reported angina at baseline. Of these patients, angina disappeared without coronary revascularization in 39.6% at 1 year, followed by further annual decreases. Among patients without angina at baseline, data indicated that 2% to 4.8% developed angina each year.
At 5-year follow-up, 7,773 patients demonstrated controlled angina, and of those, resolution was obtained with increased use of antianginal treatment in 11.1%, coronary revascularization in 4.5%, and without any changes in medication or revascularization in 84.4%.
Compared with no angina at baseline and 1 year, persistence of angina (adjusted HR = 1.32; 95% CI, 1.12-1.55) and occurrence of angina (aHR = 1.37; 95% CI, 1.11-1.7) at 1 year with conservative management independently predicted higher rates of CV death or MI at 5 years.
Furthermore, the risk for CV death or MI did not increase in patients whose angina had resolved at 1 year with conservative management compared with those who never experienced angina (aHR = 0.97; 95% CI, 0.82-1.15).
In other data, 33.9% of patients with angina at baseline still had anginal symptoms at 5 years, reflecting to researchers an unmet need for new and more effective antianginal therapy.
Mesnier and colleagues further noted that the frequency of angina resolution in the first year suggests that trials evaluating antianginal drugs may need to incorporate a longer run-in period than the short 1- to 4-week duration frequently used.
“Furthermore, it shows that medical treatment and disease-modifying interventions may take some time to be effective and relieve symptoms,” they wrote, “and the relatively low event rate of patients with stable CAD allows a period of watchful waiting before failure of medical management is declared. Finally, our observations also emphasize the importance of sham procedures when interventions are tested to relieve angina.”
The authors concluded: “Given that the benefit of antianginal medications and revascularization is restricted to symptom improvement, these observations suggest that conservative management is an effective strategy for patients with stable angina.”
Perspective
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The CLARIFY Registry refreshes memory of reports made 50 to 60 years ago, and amplified periodically, that angina is not a lifelong or permanent symptom. Neither are the accompanying ECG or stress test changes in such patients with chronic ischemic heart disease. This variable natural course contributes to the fact that it has been very difficult to prove that coronary revascularization, except in some small cohorts (left main disease, proximal left anterior descending artery obstruction or severe multivessel obstruction) improves outcomes. Importantly, the same variable natural course is true even when angina occurs without large coronary vessel obstructive lesions as observed recently in CIAO-ISCHEMIA (Reynolds HR, et al. Circulation. 2021;doi:10.1161/CIRCULATIONAHA.120.046791). This information should foster attempts to better understand gaps in our knowledge about the mechanisms underlying such phenomena.
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