Trajectories of Angina After Initial Invasive vs Conservative Strategy for Chronic Coronary Disease

Background: Clinical trials typically report average health status outcomes by treatment at single points in time, as opposed to participants’ trajectories (or journeys) over time. While ISCHEMIA demonstrated better mean health status at discrete times with an invasive treatment among those with baseline angina, the patterns of individual participants’ angina over time are unknown. Objectives: To identify patterns of individual participants’ angina over time after invasive or conservative management strategies for chronic coronary disease. Methods: In this secondary analysis of the ISCHEMIA trial, which enrolled participants with chronic coronary disease and moderate to severe ischemia from July 2012 to January 2018, we used ordinal latent trajectory analysis to assess angina frequency over a two-year period, separately for participants assigned to the initial invasive and initial conservative arms. Angina frequency was defined using the Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score, re-categorized as daily/weekly (0–60 points), monthly (61–99 points), and no angina (100 points). Participants without baseline angina were excluded. Results: Among 2977 participants with baseline angina, 1505 (50.6%) were randomized to initial invasive and 1472 (49.4%) to initial conservative management; baseline characteristics were well balanced between groups. Six distinct patterns of angina trajectories were identified in each arm and were qualitatively similar: 1) rapid resolution, 2) gradual resolution, 3) early improvement with persistent infrequent angina, 4) severe angina with improvement, 5) modest angina with minimal change, and 6) severe angina without improvement. In the invasive group, the most common patterns included rapid resolution (27.1%) and early improvement with persistent infrequent angina (32.1%), while the conservative group more often showed modest angina with minimal change (42.1%) and fewer cases of rapid resolution (12.8%) or early improvement with persistent infrequent angina (10.2%). Conclusion: Patients with chronic coronary disease and angina experienced diverse symptom trajectories, ranging from rapid resolution to severe or persistent angina. A greater proportion of conservatively managed patients experienced unfavorable angina patterns over two years compared with those treated invasively. When health status is monitored over time, such patterns may help identify patients with persistent symptoms who could benefit from additional therapy. Trial Registration: ClinicalTrials.gov Identifier: NCT01471522