Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial
Dan D Nguyen1, John A Spertus1, Karen P Alexander2
1Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA.
Insights
Invasive management improved angina frequency in older adults with chronic coronary disease but offered less health status improvement compared to younger patients. Clinical outcomes were similar across age groups for both invasive and conservative strategies.
Area of Science:
- Cardiology
- Geriatric Medicine
- Clinical Trials
Background:
- Chronic coronary disease with moderate to severe ischemia affects both younger and older adults.
- The comparative effectiveness of initial invasive versus conservative management strategies based on age is not well-established.
- Previous studies have not fully elucidated age-related differences in health status and clinical outcomes.
Purpose of the Study:
- To investigate the impact of age on health status and clinical outcomes in patients undergoing invasive versus conservative management.
- To analyze age-specific differences in the effectiveness of invasive cardiac procedures compared to conservative care.
- To evaluate the role of age in treatment decisions for chronic coronary disease patients with ischemia.
Main Methods:
- Utilized data from the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.
- Assessed one-year angina-specific health status using the Seattle Angina Questionnaire (SAQ).
- Employed Cox proportional hazards models to analyze the composite clinical outcome (cardiovascular death, myocardial infarction, or specific hospitalizations) as a function of age.
Main Results:
- Older patients (≥75 years) showed less improvement in SAQ summary scores with invasive management compared to younger patients (Pinteraction=0.008).
- Angina Frequency improvement with invasive management was less dependent on age (Pinteraction=0.08).
- No significant age-related differences were observed in the composite clinical outcome between invasive and conservative management strategies (Pinteraction=0.29).
Conclusions:
- Older adults with chronic coronary disease and ischemia experienced consistent angina frequency improvement but less health status gain with invasive management versus younger patients.
- Initial invasive management did not demonstrate superior clinical outcomes compared to conservative management in either older or younger patient groups.
- Age is a factor influencing health status improvement with invasive cardiac procedures, but not overall clinical outcomes in this patient population.
Background:
Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown.
Objectives:
The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.
Methods:
One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure.
Results:
Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29).
Conclusions:
Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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