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Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry.
JAMA Intern Med. 2014 Oct; 174(10):1651-9.JIM

Abstract

IMPORTANCE

In the era of widespread revascularization and effective antianginals, the prevalence and prognostic effect of anginal symptoms and myocardial ischemia among patients with stable coronary artery disease (CAD) are unknown.

OBJECTIVE

To describe the current clinical patterns among patients with stable CAD and the association of anginal symptoms or myocardial ischemia with clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) registry enrolled outpatients in 45 countries with stable CAD in 2009 to 2010 with 2-year follow-up (median, 24.1 months; range, 1 day to 3 years). Enrollees included 32 105 outpatients with prior myocardial infarction, chest pain, and evidence of myocardial ischemia, evidence of CAD on angiography, or prior revascularization. Of these, 20 291 (63.2%) had undergone a noninvasive test for myocardial ischemia within 12 months of enrollment and were categorized into one of the following 4 groups: no angina or ischemia (n = 13 207 [65.1%]); evidence of myocardial ischemia without angina (silent ischemia) (n = 3028 [14.9%]); anginal symptoms alone (n = 1842 [9.1%]); and angina and ischemia (n = 2214 [10.9%]).

EXPOSURES

Stable CAD.

MAIN OUTCOME AND MEASURE

The composite of cardiovascular (CV)-related death or nonfatal myocardial infarction.

RESULTS

Overall, 4056 patients (20.0%) had anginal symptoms and 5242 (25.8%) had evidence of myocardial ischemia on results of noninvasive testing. Of 469 CV-related deaths or myocardial infarctions, 58.2% occurred in patients without angina or ischemia, 12.4% in patients with ischemia alone, 12.2% in patients with angina alone, and 17.3% in patients with both. The hazard ratios for the primary outcome relative to patients without angina or ischemia and adjusted for age, sex, geographic region, smoking status, hypertension, diabetes mellitus, and dyslipidemia were 0.90 (95% CI, 0.68-1.20; P = .47) for ischemia alone, 1.45 (95% CI, 1.08-1.95; P = .01) for angina alone, and 1.75 (95% CI, 1.34-2.29; P < .001) for both. Similar findings were observed for CV-related death and for fatal or nonfatal myocardial infarction.

CONCLUSIONS AND RELEVANCE

In outpatients with stable CAD, anginal symptoms (with or without ischemia on noninvasive testing) but not silent ischemia appear to be associated with an increased risk for adverse CV outcomes. Most CV events occurred in patients without angina or ischemia.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN43070564.

Authors+Show Affiliations

Université Paris-Diderot, Sorbonne Paris-Cité, Paris, France2Unit 1148, Institut National de la Santé et de la Recherche Médicale, Paris, France3Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodeling), Department of Cardiology, HôRobertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland.Third Division of Cardiology, Medical University of Silesia, Katowice, Poland.Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.Department of Cardiology and Laboratory for Technologies of Advanced Therapies Centre, University Hospital of Ferrara and Maria Cecilia Hospital, Ferrara, Italy9Maria Cecili Hospital, Gruppo Villa Maria Care & Research, Ettore Sansavini Health Science Fou.King Abdul-Aziz Cardiac Center, National Guard Health Affairs, Riyadh, Saudi Arabia.Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.Heart Institute, Peking University People's Hospital, Beijing, China.State Research Centre for Preventive Medicine, Moscow, Russia.Department of Cardiology, Institute Adrogue, Buenos Aires, Argentina15Department of Cardiology, University Buenos Aires, Buenos Aires, Argentina.Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland.National Heart and Lung Institute, Imperial College, Institute of Cardiovascular Medicine and Sciences, Royal Brompton Hospital, London, England.No affiliation info available

Pub Type(s)

Clinical Trial
Journal Article
Multicenter Study
Observational Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

25110899

Citation

Steg, Philippe Gabriel, et al. "Prevalence of Anginal Symptoms and Myocardial Ischemia and Their Effect On Clinical Outcomes in Outpatients With Stable Coronary Artery Disease: Data From the International Observational CLARIFY Registry." JAMA Internal Medicine, vol. 174, no. 10, 2014, pp. 1651-9.
Steg PG, Greenlaw N, Tendera M, et al. Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry. JAMA Intern Med. 2014;174(10):1651-9.
Steg, P. G., Greenlaw, N., Tendera, M., Tardif, J. C., Ferrari, R., Al-Zaibag, M., Dorian, P., Hu, D., Shalnova, S., Sokn, F. J., Ford, I., & Fox, K. M. (2014). Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry. JAMA Internal Medicine, 174(10), 1651-9. https://doi.org/10.1001/jamainternmed.2014.3773
Steg PG, et al. Prevalence of Anginal Symptoms and Myocardial Ischemia and Their Effect On Clinical Outcomes in Outpatients With Stable Coronary Artery Disease: Data From the International Observational CLARIFY Registry. JAMA Intern Med. 2014;174(10):1651-9. PubMed PMID: 25110899.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry. AU - Steg,Philippe Gabriel, AU - Greenlaw,Nicola, AU - Tendera,Michal, AU - Tardif,Jean-Claude, AU - Ferrari,Roberto, AU - Al-Zaibag,Muayed, AU - Dorian,Paul, AU - Hu,Dayi, AU - Shalnova,Svetlana, AU - Sokn,Fernando José, AU - Ford,Ian, AU - Fox,Kim M, AU - ,, PY - 2014/8/12/entrez PY - 2014/8/12/pubmed PY - 2015/1/31/medline SP - 1651 EP - 9 JF - JAMA internal medicine JO - JAMA Intern Med VL - 174 IS - 10 N2 - IMPORTANCE: In the era of widespread revascularization and effective antianginals, the prevalence and prognostic effect of anginal symptoms and myocardial ischemia among patients with stable coronary artery disease (CAD) are unknown. OBJECTIVE: To describe the current clinical patterns among patients with stable CAD and the association of anginal symptoms or myocardial ischemia with clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) registry enrolled outpatients in 45 countries with stable CAD in 2009 to 2010 with 2-year follow-up (median, 24.1 months; range, 1 day to 3 years). Enrollees included 32 105 outpatients with prior myocardial infarction, chest pain, and evidence of myocardial ischemia, evidence of CAD on angiography, or prior revascularization. Of these, 20 291 (63.2%) had undergone a noninvasive test for myocardial ischemia within 12 months of enrollment and were categorized into one of the following 4 groups: no angina or ischemia (n = 13 207 [65.1%]); evidence of myocardial ischemia without angina (silent ischemia) (n = 3028 [14.9%]); anginal symptoms alone (n = 1842 [9.1%]); and angina and ischemia (n = 2214 [10.9%]). EXPOSURES: Stable CAD. MAIN OUTCOME AND MEASURE: The composite of cardiovascular (CV)-related death or nonfatal myocardial infarction. RESULTS: Overall, 4056 patients (20.0%) had anginal symptoms and 5242 (25.8%) had evidence of myocardial ischemia on results of noninvasive testing. Of 469 CV-related deaths or myocardial infarctions, 58.2% occurred in patients without angina or ischemia, 12.4% in patients with ischemia alone, 12.2% in patients with angina alone, and 17.3% in patients with both. The hazard ratios for the primary outcome relative to patients without angina or ischemia and adjusted for age, sex, geographic region, smoking status, hypertension, diabetes mellitus, and dyslipidemia were 0.90 (95% CI, 0.68-1.20; P = .47) for ischemia alone, 1.45 (95% CI, 1.08-1.95; P = .01) for angina alone, and 1.75 (95% CI, 1.34-2.29; P < .001) for both. Similar findings were observed for CV-related death and for fatal or nonfatal myocardial infarction. CONCLUSIONS AND RELEVANCE: In outpatients with stable CAD, anginal symptoms (with or without ischemia on noninvasive testing) but not silent ischemia appear to be associated with an increased risk for adverse CV outcomes. Most CV events occurred in patients without angina or ischemia. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN43070564. SN - 2168-6114 UR - https://www.unboundmedicine.com/medline/citation/25110899/Prevalence_of_anginal_symptoms_and_myocardial_ischemia_and_their_effect_on_clinical_outcomes_in_outpatients_with_stable_coronary_artery_disease:_data_from_the_International_Observational_CLARIFY_Registry_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2014.3773 DB - PRIME DP - Unbound Medicine ER -