Post-MI angina common, underappreciated, undertreated in registry study

June 24, 2008

Chicago, IL - One in five patients with an 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 CABG surgery, and recurrent angina at rest during the MI hospitalization and with smoking and depression after discharge, report the authors, led by D r 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

Any (%) Daily (%) Weekly (%) Less often (%)
19.9 1.2 3.0 15.6

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

Characteristic RR (95% CI)
New depression * 1.96 (1.34-2.87)
Prior CABG surgery 1.92 (1.51-2.44)
Prior angina 1.78 (1.54-2.06)
Recurrent rest angina at index hospitalization 1.54 (1.22-1.93)
Nonwhite male 1.50 (1.16-1.96)
Continued smoking after discharge 1.23 (1.02-1.48)
Younger age ( R R per 10-year decrease) 1.19 (1.09-1.30)
*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."

T he analysis was supported parti ally by CV Therapeutics; coauthor Dr John A Spertus (Mid-America Heart Institute , Kansas City, MO ) owns the copyright for the Seattle Angina Questionnaire .


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