Factors Associated With Coronary Angiography Performed Within 6 Months of Randomization to the Conservative Strategy
Radosław Pracoń1, John A Spertus2, Samuel Broderick3
1National Institute of Cardiology, Warsaw, Poland (R.P., W.R.).
Insights
In the ISCHEMIA trial, less than 10% of patients on a conservative strategy underwent early angiography. Angina frequency and quality of life, not disease severity, predicted this decision.
Area of Science:
- Cardiology
- Clinical Trials
- Interventional Cardiology
Background:
- The International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial found no overall benefit of an invasive over a conservative strategy for chronic coronary disease.
- However, some patients in the conservative group underwent early invasive coronary angiography.
- Understanding factors influencing this decision is crucial for clinical practice.
Purpose of the Study:
- To identify factors associated with early invasive coronary angiography in patients with chronic coronary disease randomized to a conservative management strategy.
- To inform clinical decision-making regarding the optimal treatment approach for these patients.
Main Methods:
- Analysis of data from 2591 participants in the ISCHEMIA trial randomized to the conservative strategy.
- Utilized Fine and Gray proportional subdistribution hazard models to assess factors associated with angiography within 6 months of randomization.
- Included demographics, region, medical history, risk factors, symptoms, ischemia severity, coronary anatomy (CT angiography), and medication use.
Main Results:
- Early angiography occurred in 8.7% of conservative strategy participants.
- Associated factors included enrollment in Europe, daily/weekly angina, poor health status, and new/more frequent angina.
- Well-controlled low-density lipoprotein cholesterol (<70 mg/dL) was associated with reduced angiography risk.
- Ischemia severity and coronary anatomy did not predict early angiography.
Conclusions:
- Early angiography in the ISCHEMIA conservative arm was infrequent (<10%) and driven by symptoms and quality of life, not objective disease severity.
- Factors like angina frequency and health status influenced the decision for early invasive procedures.
- Optimizing medical therapy and comprehensive symptom assessment are key when choosing initial treatment strategies for chronic coronary disease.
Background:
ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) did not find an overall reduction in cardiovascular events with an initial invasive versus conservative management strategy in chronic coronary disease; however, there were conservative strategy participants who underwent invasive coronary angiography early postrandomization (within 6 months). Identifying factors associated with angiography in conservative strategy participants will inform clinical decision-making in patients with chronic coronary disease.
Methods:
Factors independently associated with angiography performed within 6 months of randomization were identified using Fine and Gray proportional subdistribution hazard models, including demographics, region of randomization, medical history, risk factor control, symptoms, ischemia severity, coronary anatomy based on protocol-mandated coronary computed tomography angiography, and medication use.
Results:
Among 2591 conservative strategy participants, angiography within 6 months of randomization occurred in 8.7% (4.7% for a suspected primary end point event, 1.6% for persistent symptoms, and 2.6% due to protocol nonadherence) and was associated with the following baseline characteristics: enrollment in Europe versus Asia (hazard ratio [HR], 1.81 [95% CI, 1.14-2.86]), daily and weekly versus no angina (HR, 5.97 [95% CI, 2.78-12.86] and 2.63 [95% CI, 1.51-4.58], respectively), poor to fair versus good to excellent health status (HR, 2.02 [95% CI, 1.23-3.32]) assessed with Seattle Angina Questionnaire, and new/more frequent angina prerandomization (HR, 1.80 [95% CI, 1.34-2.40]). Baseline low-density lipoprotein cholesterol <70 mg/dL was associated with a lower risk of angiography (HR, 0.65 [95% CI, 0.46-0.91) but not baseline ischemia severity nor the presence of multivessel or proximal left anterior descending artery stenosis >70% on coronary computed tomography angiography.
Conclusions:
Among ISCHEMIA participants randomized to the conservative strategy, angiography within 6 months of randomization was performed in <10% of patients. It was associated with frequent or increasing baseline angina and poor quality of life but not with objective markers of disease severity. Well-controlled baseline low-density lipoprotein cholesterol was associated with a reduced likelihood of angiography. These findings point to the importance of a comprehensive assessment of symptoms and a review of guideline-directed medical therapy goals when deciding the initial treatment strategy for chronic coronary disease.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.
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