from Heartwire — a professional news service of WebMD

June 25, 2008 — One in five patients with a myocardial infarction (MI) experienced angina one year after hospitalization for the acute event, and a substantial minority of those with angina had symptoms at least weekly, in a prospective, multicenter registry analysis appearing in the June 23, 2008 Archives of Internal Medicine [1].

Their angina was independently associated with younger age, a history of coronary artery bypass graft (CABG) surgery, and recurrent angina at rest during the MI hospitalization and with smoking and depression after discharge, report the authors, led by Dr Thomas M Maddox (Denver Veterans Affairs Medical Center, CO). Their report is based on almost 2000 patients from the Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery (PREMIER) registry.

Only about two-thirds of the patients with post-MI angina reported taking beta blockers, three-quarters were on statins, and only half were taking nitrates, according to the data, which covered the years 2003 to 2005.

The findings underscore the importance of angina in the post-MI setting and show how undertreated it is, according to coauthor Dr John S Rumsfeld (Denver Veterans Affairs Medical Center). They also show several important risk predictors "that are appealing as targets for improving outcomes," in particular, smoking and depression.

"This provides a major focus for post-MI care that just hasn't been present heretofore," Rumsfeld told heartwire . The treatment of acute MI is so often thought of as occurring during the hospitalization, "but we're starting to think of that as the beginning of a longer episode of continuous care. Over the year after an acute MI, we need to watch for angina and be vigilant about it to optimize patient outcomes."

The patients from 19 US hospitals were evaluated one year after their MI hospitalization using the Seattle Angina Questionnaire, particularly the instrument's angina-frequency subscale that looks at symptom occurrence within the previous four weeks, according to Maddox et al. About 20% of the cohort reported experiencing angina, at least weekly in about 4%.

Proportion of 1957 patients hospitalized with MI who, one year later, reported any angina or daily, weekly, or less-than weekly angina

In a multivariate analysis that accounted for demographics, health-insurance factors, clinical history, prior angina, MI presentation, and therapies received in the hospital, as well as postdischarge therapies, clinical events, physician visits, smoking, and procedures, angina at one year was independently associated with younger age, prior angina, smoking, depression, and other features.

Significant independent predictors of relative risk of angina at one year in the PREMIER registry

*As assessed using the nine-item Patient Health Questionnaire

Of those with angina at one year, 76% were on statins, 12% were taking calcium-channel blockers, 69% were on beta blockers, and 51% were on nitrates; of those medications, only the nitrates were used significantly more among those with vs without angina (< 0.001).

Rumsfeld said those figures, representative as they are of US practice, show big opportunities for improving the medical therapy of post-MI angina. "Right now our healthcare system is set up to provide care in small episodes: either you're in the hospital or not, or in the clinic or not. And that's not a patient-centered healthcare model," he said. "We have such advanced care for the acute event. Maybe the next phase of real quality improvement that will make a real difference to patients' quality of life and how long they live is [to focus on] having an effective transition home and handoff to the [primary]-care providers over the following year."

The analysis was supported partially by CV Therapeutics, Palo Alto, California, and the National Institutes of Health Specialized Centers of Clinically Oriented Research. Coauthor Dr. John A Spertus (Mid-America Heart Institute, Kansas City, Missouri) owns the copyright for the Seattle Angina Questionnaire.

Source

1. Maddox TM, Reid KJ, Spertus JA, et al. Angina at 1 year after myocardial infarction: Prevalence and associated findings. Arch Intern Med. 2008;168:1310-1316.

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Clinical Context

Study Highlights

• Included were 2498 patients with acute MI from 19 US hospitals who were tracked as outpatients 1 year after hospitalization for acute MI.
• Cardiac health status was measured with the Seattle Angina Questionnaire, which is a 19-item, disease-specific health status instrument quantifying symptoms, physical functioning, and health-related quality of life.
• Scores were from 0 to 100, with higher scores indicating better outcomes.
• Depressive symptoms were measured with the 9-item Patient Health Questionnaire, with higher scores indicating greater depressive symptoms.
• Angina was assessed with the Seattle Angina Questionnaire angina frequency subscale, which assessed angina within the previous 4 weeks.
• Patient activity was controlled for to account for lower angina rates from sedentary lifestyle.
• Factors were grouped into sociodemographic, coronary artery disease risk factors (inpatient and antecedent), and outpatient factors.
• Outpatient factors included participation in cardiac rehabilitation; early discharge; follow-up clinician visits; smoking cessation; revascularization after index hospitalization; medication adherence to beta-blockers, aspirin, and statins; and depressive symptoms.
• Categories of smoking cessation were nonsmokers, quitters, and persistent smokers.
• Categories of depression were severe, transient, persistent, and new.
• Of 2498 patients, 199 died before the 1-year interview and 343 (14.9%) did not undergo an interview.
• Of the remaining 1957 patients, 19.9% (1 in 5) reported angina 1 year after hospitalization for MI.
• 1.2% reported daily angina, 3.0% reported weekly angina, and 15.6% reported angina less than once a week.
• Patients with angina 1 year after MI were more likely to be younger (relative risk [RR], 1.19 per 10-year increase), nonwhite (RR, 1.50 for nonwhite men), less educated, and have less insurance.
• They were more likely to have previous cardiac disease, angina before the MI (RR, 1.78), and more cardiac risk factors including having undergone previous coronary artery bypass graft surgery (RR, 1.92).
• They had more depressive symptoms and higher smoking rates.
• Patients with angina at 1 year were more likely to continue smoking (RR, 1.23); undergo revascularization after the index hospitalization (RR, 1.37); and to have new (RR, 1.96), persistent (RR, 1.88), or transient (RR, 1.77) depressive symptoms.
• Those with angina at 1 year were as likely as those without angina to be taking calcium channel blockers (12.1% vs 11.4%) and beta-blockers (69.2% vs 70.0%) and more likely to be taking nitrates (51.4% vs 32.4%).
• At 1 year, 87.9% of those with angina were not taking calcium channel blockers, 30.8% were not taking beta-blockers, and 48.6% were not taking nitrates.

Pearls for Practice

• There are 1 in 5 patients with MI who experience angina 1 year later; among them, 1 in 5 experience angina symptoms daily or weekly.
• Patients with persistent angina at 1 year after the index MI are more likely to be young; nonwhite; men with cardiac risk factors and previous angina; and to have persistent smoking, revascularization, and depression.

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