International Observational Analysis of Evolution and Outcomes of Chronic Stable Angina

Angina pectoris is a common manifestation of stable coronary artery disease (CAD) and negatively affects quality of life. Lifestyle changes, pharmacological treatment, and coronary revascularization can improve symptoms. However, in most randomized trials exploring antianginal strategies or drugs in stable CAD, the burden of angina improved over time in the

control group. Although this improvement could be a result of optimization of medical treatments and cardiovascular risk factors during the trial, it could also reflect the natural history of the condition.

Angina pectoris is also associated with poor outcomes. However, antianginal treatments have not been proven to improve outcomes in chronic stable angina. Even β-blockers, largely used on the basis of a mortality reduction after myocardial infarction, have not been associated with improved outcomes in stable angina. Likewise, invasive management with a view to coronary revascularization does not reduce the risk of death or myocardial infarction in patients with stable angina or myocardial ischemia, although it improves symptoms.

Angina still affects almost one-quarter of patients with stable CAD. In a well-treated population, anginal symptoms resolve in the majority of patients over time, most often without revascularization or changes in antianginal therapy. Changes in anginal status without coronary revascularization are associated with cardiovascular outcomes. Whereas resolution of angina

is associated with improved outcomes, appearance or persistence of angina is associated with poor outcomes. Given that the benefit of antianginal medications and revascularization is restricted to symptom improvement, these observations suggest that conservative management is an effective strategy for patients with stable angina.

What Is New?

• Angina affects almost one-quarter of patients with stable coronary artery disease but resolves with conservative management and without cardiovascular events in most patients.

• In this medically well-treated population, angina largely resolves without changes in medication or revascularization.

• Resolution of angina within 1 year with conservative management predicted outcomes similar to absence of angina, whereas persistence or occurrence was associated with poor cardiovascular outcomes.

What Are the Clinical Implications?

• Given that the benefit of antianginal medications and revascularization is restricted to symptom

improvement in stable coronary artery disease, this study suggests that conservative management is an effective strategy for patients with stable angina.

• The low rate of cardiovascular events and favorable evolution of angina in most patients allow for a watchful waiting strategy before failure of medical management is declared.

• The frequency of resolution of angina in the first year suggests that trials testing antianginal drugs may need to incorporate a longer run-in period.

SCAC 07/22 ANG 001 MPAD