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Variation in Health Status With Invasive vs Conservative Management of Chronic Coronary Disease
Suzanne V Arnold1, Philip G Jones1, David J Maron2
1University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.
Insights
The ISCHEMIA trial showed invasive strategies improved health status for chronic coronary disease patients. Younger patients and those with worse baseline health benefit most from invasive approaches, aiding personalized treatment decisions.
Area of Science:
- Cardiology
- Clinical Trials
- Health Outcomes Research
Background:
- The ISCHEMIA trial indicated an invasive strategy improved health status in chronic coronary disease (CCD) patients compared to a conservative approach.
- Translating these population-level findings to individual patient care remains a challenge.
Purpose of the Study:
- To identify patient characteristics influencing health status outcomes in CCD patients undergoing invasive versus conservative management.
- To develop a predictive algorithm for shared decision-making, personalizing treatment strategies.
Main Methods:
- Assessed one-year disease-specific health status using the Seattle Angina Questionnaire (SAQ) Summary Score (SAQ SS) and its domains (Angina Frequency, Physical Limitations, Quality of Life).
- Analyzed data from 4,617 patients across 320 sites in 37 countries.
- Developed parsimonious prediction models for 1-year SAQ domains based on patient characteristics and treatment strategy.
Main Results:
- Mean SAQ SS improved from 74.1 at baseline to 85.7 at one year.
- Younger age and lower baseline SAQ SS were linked to better one-year health status with an invasive strategy.
- Significant treatment interactions showed greater benefit from invasive management for patients with worse baseline health, younger age, anterior ischemia, and those on more antianginal medications.
Conclusions:
- Individual patient characteristics, particularly younger age and poorer angina-related health status, predict greater benefit from invasive management in CCD.
- The developed prediction algorithm facilitates the application of ISCHEMIA trial findings to individual patient care and shared decision-making.
Background:
The ISCHEMIA trial found that patients with chronic coronary disease randomized to invasive strategy had better health status than those randomized to conservative strategy. It is unclear how best to translate these population-level results to individual patients.
Objectives:
The authors sought to identify patient characteristics associated with health status from invasive and conservative strategies, and develop a prediction algorithm for shared decision-making.
Methods:
One-year disease-specific health status was assessed in ISCHEMIA with the Seattle Angina Questionnaire (SAQ) Summary Score (SAQ SS) and Angina Frequency, Physical Limitations (PL), and Quality of Life (QL) domains (range 0-100, higher = less angina/better health status).
Results:
Among 4,617 patients from 320 sites in 37 countries, mean SAQ SS was 74.1 ± 18.9 at baseline and 85.7 ± 15.6 at 1 year. Lower baseline SAQ SS and younger age were associated with better 1-year health status with invasive strategy (P interaction = 0.009 and P interaction = 0.004, respectively). For the individual domains, there were significant treatment interactions for baseline SAQ score (Angina Frequency, PL), age (PL, QL), anterior ischemia (PL), and number of baseline antianginal medications (QL), with more benefit of invasive in patients with worse baseline health status, younger age, anterior ischemia, and on more antianginal medications. Parsimonious prediction models were developed for 1-year SAQ domains with invasive or conservative strategies to support shared decision-making.
Conclusions:
In the management of chronic coronary disease, individual patient characteristics are associated with 1-year health status, with younger age and poorer angina-related health status showing greater benefit from invasive management. This prediction algorithm can support the translation of the ISCHEMIA trial results to individual patients. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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