The Impact of De-escalation of Antianginal Medications on Health Status After Percutaneous Coronary Intervention.

Antianginal medications (AAMs) can be perceived to be less important after percutaneous coronary intervention (PCI) and may be de-escalated after revascularization. We examined the frequency of AAM de-escalation at discharge post-PCI and its association with follow-up health status. In a 10-center PCI registry, the Seattle Angina Questionnaire was assessed before and 6 months post-PCI. AAM de-escalation was defined as fewer AAMs at discharge versus admission or >25% absolute dose decrease. Of 2743 PCI patients (70% male), AAM were de-escalated, escalated, and unchanged in 299 (11%), 714 (26%), and 1730 (63%) patients, respectively. Patients whose AAM were de-escalated were more likely to report angina at 6 months, compared with unchanged or escalated AAM (34% versus 24% versus 21%; P<0.001). The association of AAM de-escalation with health status was examined using multivariable models adjusting for the predicted risk of post-PCI angina, completeness of revascularization, and the interaction of AAM de-escalation×completeness of revascularization. There was a significant interaction between AAM de-escalation and completeness of revascularization (P<0.001), suggesting that AAM de-escalation was associated with greater impairment of health status among patients with incomplete revascularization. In patients with incomplete revascularization, de-escalation of AAM at discharge was associated with 43% increased angina risk (relative risk, 1.43; 95% confidence interval, 1.26-1.63) and worse angina-related health status at 6 months post-PCI. De-escalation of AAM occurs in 1 in 10 patients post-PCI, and it is associated with an increased risk of angina and worse health status, particularly among those with incomplete revascularization.

Qintar M ，Towheed A ，Tang F ，Salisbury AC ，Ho PM ，Grantham JA ，Spertus JA ，Arnold SV ... -  《Journal of the American Heart Association》

Patient Characteristics Associated With Antianginal Medication Escalation and De-Escalation Following Chronic Total Occlusion Percutaneous Coronary Intervention.

Hirai T ，Qintar M ，Grantham JA ，Sapontis J ，Cohen DJ ，Lombardi W ，Karmpaliotis D ，Moses J ，Nicholson WJ ，Nugent K ，Gosch KL ，Spertus JA ，Salisbury AC ... -  《Circulation-Cardiovascular Quality and Outcomes》

De-escalation of antianginal medications after successful chronic total occlusion percutaneous coronary intervention: Frequency and relationship with health status.

Successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can markedly reduce angina symptom burden, but many patients often remain on multiple antianginal medications (AAMs) after the procedure. It is unclear when, or if, AAMs can be de-escalated to prevent adverse effects or limit polypharmacy. We examined the association of de-escalation of AAMs after CTO PCI with long-term health status. In a 12-center registry of consecutive CTO PCI patients, health status was assessed at 6 months after successful CTO PCI with the Seattle Angina Questionnaire and the Rose Dyspnea Scale. Among patients with technical CTO PCI success, we examined the association of AAM de-escalation with 6-month health status using multivariable models adjusting for revascularization completeness and predicted risk of post-PCI angina (using a validated risk model). We also examined predictors and variability of AAMs de-escalation. Of 669 patients with technical success of CTO PCI, AAMs were de-escalated in 276 (35.9%) patients at 1 month. Patients with AAM de-escalation reported similar angina and dyspnea rates at 6 months compared with those whose AAMs were reduced (any angina: 22.5% vs 20%, P = .43; any dyspnea: 51.8% vs 50.1%, P = .40). In a multivariable model adjusting for complete revascularization and predicted risk of post-PCI angina, de-escalation of AAMs at 1 month was not associated with an increased risk of angina, dyspnea, or worse health status at 6 months. Among patients with successful CTO PCI, de-escalation of AAMs occurred in about one-third of patients at 1 month and was not associated with worse long-term health status.

Qintar M ，Hirai T ，Arnold SV ，Sheehy J ，Sapontis J ，Jones P ，Tang Y ，Lombardi W ，Karmpaliotis D ，Moses J ，Patterson C ，Nicholson WJ ，Cohen DJ ，Spertus JA ，Grantham JA ，Salisbury AC ... -  《-》

Anti-anginal medication titration among patients with residual angina 6-months after chronic total occlusion percutaneous coronary intervention: insights from OPEN CTO registry.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been shown to reduce angina and improve quality of life, but the frequency of new or residual angina after CTO PCI and its relationship with titration of anti-anginal medications (AAMs) has not been described. Among consecutive CTO PCI patients treated at 12 US centres in the OPEN CTO registry, angina was assessed 6 months after the index PCI using the Seattle Angina Questionnaire (SAQ) Angina Frequency scale (a score <100 defined new or residual angina). We then compared the proportion of patients with AAM escalation (defined as an increase in the number or dosage of AAMs between discharge and follow-up) between those with and without 6-month angina. Of 901 patients who underwent CTO PCI, 197 (21.9%) reported angina at 6-months, of whom 80 (40.6%) had de-escalation, 66 (33.5%) had no change, and only 51 (25.9%) had escalation of their AAM by the 6-month follow-up. Rates of AAM escalation were similar when stratifying patients by the ultimate success of the CTO PCI, completeness of physiologic revascularization, presence or absence of angina at baseline, history of heart failure, and by degree of symptomatic improvement after CTO PCI. One in five patients reported angina 6 months after CTO PCI. Although patients with new or residual angina were more likely to have escalation of AAMs in follow-up compared with those without residual symptoms, only one in four patients with residual angina had escalation of AAMs. Although it is unclear whether this finding reflects maximal tolerated therapy at baseline or therapeutic inertia, these findings suggest an important potential opportunity to further improve symptom control in patients with complex stable ischaemic heart disease.

Sheehy JP ，Qintar M ，Arnold SV ，Hirai T ，Sapontis J ，Jones PG ，Tang Y ，Lombardi W ，Karmpaliotis D ，Moses JW ，Patterson C ，Cohen DJ ，Amin AP ，Nicholson WJ ，Spertus JA ，Grantham JA ，Salisbury AC ... -  《-》

Management of Persistent Angina After Myocardial Infarction Treated With Percutaneous Coronary Intervention: Insights From the TRANSLATE-ACS Study.

Angina has important implications for patients' quality of life and healthcare utilization. Angina management after acute myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) is unknown. TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) was a longitudinal study of MI patients treated with percutaneous coronary intervention at 233 US hospitals from 2010 to 2012. Among patients with self-reported angina at 6 weeks post-MI, we described patterns of angina and antianginal medication use through 1 year postdischarge. Of 10 870 percutaneous coronary intervention-treated MI patients, 3190 (29.3%) reported angina symptoms at 6 weeks post-MI; of these, 658 (20.6%) had daily/weekly angina while 2532 (79.4%) had monthly angina. Among patients with 6-week angina, 2936 (92.0%) received β-blockers during the 1 year post-MI, yet only 743 (23.3%) were treated with other antianginal medications. At 1 year, 1056 patients (33.1%) with 6-week angina reported persistent angina symptoms. Of these, only 31.2% had been prescribed non-β-blocker antianginal medications at any time in the past year. Among patients undergoing revascularization during follow-up, only 25.9% were on ≥1 non-β-blocker anti-anginal medication at the time of the procedure. Angina is present in one third of percutaneous coronary intervention-treated MI patients as early as 6 weeks after discharge, and many of these patients have persistent angina at 1 year. Non-β-blocker antianginal medications are infrequently used in these patients, even among those with persistent angina and those undergoing revascularization.

Fanaroff AC ，Kaltenbach LA ，Peterson ED ，Hess CN ，Cohen DJ ，Fonarow GC ，Wang TY ... -  《Journal of the American Heart Association》