Prognosis of stable angina pectoris: why we need larger population studies with higher endpoint resolution
Adam D Timmis1, Gene Feder, Harry Hemingway
1Cardiac Directorate, Barts and The London NHS Trust, London, UK. adamtimmis@mac.com
Insights
Angina prognosis has shifted from "unhappy" to "good" due to clinical trials. However, recent data indicate angina remains high-risk for chest pain clinic patients, highlighting the need for better risk stratification and understanding of coronary artery disease phenotypes.
Area of Science:
- Cardiology
- Clinical Epidemiology
- Public Health
Background:
- Historical prognosis for angina was poor, comparable to myocardial infarction survivors.
- Recent clinical trials suggest a significantly improved prognosis for angina patients.
- Discrepancies in prognosis may stem from differences between population cohorts and selected trial participants.
Purpose of the Study:
- To reconcile disparate prognostic assessments of angina.
- To investigate the prognosis of angina in patients presenting with recent onset symptoms.
- To emphasize the need for improved understanding of coronary artery disease phenotypes.
Main Methods:
- Review of historical data (Framingham investigators).
- Analysis of recent clinical trial outcomes.
- Evaluation of data from patients attending chest pain clinics with recent onset symptoms.
Main Results:
- Angina prognosis has improved in clinical trial settings.
- For patients with recent onset symptoms in chest pain clinics, angina remains a high-risk diagnosis.
- Revascularization often provides symptomatic relief but does not significantly alter prognosis for these patients.
Conclusions:
- Angina's prognosis varies significantly between general populations and selected trial groups.
- Stable angina lacks a universally agreed case definition, complicating comparisons.
- Early detection, risk stratification, and treatment are crucial for modifying outcomes in coronary artery disease, given angina's prevalence.
- Further population-based studies are needed to understand the full patient journey and prognostic differences across coronary disease phenotypes.
Abstract:
The prognosis of angina was described as "unhappy" by the Framingham investigators and as little different from that of 1-year survivors of acute myocardial infarction. Yet recent clinical trials now report that angina has a good prognosis with adverse outcomes reduced to "normal levels". These disparate prognostic assessments may not be incompatible, applying as they do to population cohorts (Framingham) and selected participants in clinical trials. Comparisons between studies are further complicated by the absence of agreed case definitions for stable angina (contrast this with acute coronary syndromes). Our recent data show that for patients with recent onset symptoms attending chest pain clinics, angina remains a high-risk diagnosis and although many patients receive symptomatic benefit from revascularisation, prognosis is usually unaffected. This leaves little room for complacency and, with angina the commonest initial manifestation of coronary artery disease, there is the opportunity for early detection, risk stratification and treatment to modify outcomes. Meanwhile, larger population-based studies are needed to define the patient journey from earliest presentation through the various syndrome transitions to coronary or noncardiac death in order to increase understanding of the aetiological and prognostic differences between the different coronary disease phenotypes.
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