Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease

Q: What are the key findings of this study?

Invasive management yielded smaller 1-year SAQ Summary Score gains in older vs younger adults (MD 2.13 at age 75 vs 4.90 at age 55; p-interaction=0.008) with no difference in clinical outcomes.

Q: What is the clinical evidence from this study?

Study design: RCT. Population: Chronic coronary disease with moderate or severe ischemia (n=4617). Intervention: Routine invasive management strategy (guideline-directed medical therapy with angiography and revascularization if feasible) vs. Conservative management strategy (guideline-directed medical therapy only, with angiography and revascularization reserved for failure of medical therapy). Primary outcome: 1-year angina-specific health status measured by 7-item Seattle Angina Questionnaire (SAQ) Summary Score (at age 75) (MD 2.13, 95% CI 0.75, 3.51, p=0.008 for interaction).

Q: What does this research mean for the field?

In patients with chronic coronary disease and moderate-to-severe ischemia, initial invasive management yields smaller 1-year angina-related health status improvements in older adults compared with younger adults, with no significant difference in clinical outcomes across age groups. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Dan D. Nguyen; John A. Spertus; Karen P. Alexander; Jonathan D. Newman; John A. Dodson; Philip G. Jones; Susanna R. Stevens; Sean M. O’Brien; Reto Andreas Gamma; Gian Piero Perna; Pallav Garg; João Vicente Vitola; Benjamin J.W. Chow; András Vértes; Harvey Douglas White; Paola E. P. Smanio; Roxy Senior; Claes Held; Jianghao Li; William E. Boden; Daniel B. Mark; Harmony R. Reynolds; Sripal Bangalore; Paul S. Chan; Gregg W. Stone; Suzanne V. Arnold; David Joel Maron; Judith S. Hochman

doi:10.1016/j.jacc.2023.02.048

Key result

Invasive strategy yields smaller angina gains in older adults, improving SAQ scores by only ~2 points.

MD 2.13
95% CI 0.75, 3.51
P=0.008 for interaction
n=4,617

Why the study?

Whether initial invasive management in older versus younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes was unknown.

Does an initial invasive management strategy compared with conservative management improve 1-year angina-related health status and clinical outcomes in older versus younger adults with chronic coronary disease and moderate or severe ischemia?

Key Points

To assess how age modifies the effect of invasive versus conservative management on health status and clinical outcomes among patients with chronic coronary disease and moderate or severe ischemia.
Secondary analysis of 4617 participants randomized in the ISCHEMIA trial, stratified by age: <65 years (n=2239; 48.5%), 65–74 years (n=1713; 37.1%), and ≥75 years (n=665; 14.4%).
Angina-specific health status was measured at 1 year using the 7-item Seattle Angina Questionnaire (SAQ; score range 0–100).
Cox proportional hazards models evaluated clinical outcomes across age over a median follow-up of 3.2 years for a composite of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure.
Fully adjusted differences in 1-year SAQ Summary Scores (invasive minus conservative) declined with advancing age: 4.90 (95% CI 3.56, 6.24) at age 55, 3.48 (95% CI 2.40, 4.57) at age 65, and 2.13 (95% CI 0.75, 3.51) at age 75 (interaction P=0.008).
Improvement in SAQ Angina Frequency was less dependent on age across treatment groups (interaction P=0.07).
No significant difference by age occurred for the composite clinical outcome between management strategies (interaction P=0.29), with adjusted HRs of 0.81 (95% CI 0.62 to 1.07) at age 55, 0.90 (95% CI 0.76, 1.06) at age 65, and 0.99 (95% CI 0.80, 1.22) at age 75.

Study Design

Type

RCT (n=4,617)

Blinding

Unblinded

Randomization

1:1 parallel assignment

Multicenter

Yes

Structured PICO

Does an initial invasive management strategy compared with conservative management improve 1-year angina-related health status and clinical outcomes in older versus younger adults with chronic coronary disease and moderate or severe ischemia?

P

Population

4,617 adults (median age 65 years) with chronic coronary disease and moderate or severe ischemia on stress testing, followed for a median of 3.2 years for clinical outcomes and 12 months for health status.

I

Intervention

Routine invasive strategy consisting of guideline-directed medical therapy (GDMT) plus cardiac angiography and revascularization (PCI or CABG) if feasible.

C

Comparator

Conservative strategy consisting of guideline-directed medical therapy (GDMT) alone, with angiography and revascularization reserved for failure of medical therapy.

O

Outcome

1-year angina-specific health status assessed with the 7-item Seattle Angina Questionnaire (SAQ) Summary Score (range 0–100; higher = better health status) and the primary composite clinical outcome of cardiovascular death, non-fatal myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure over median 3.2 years follow-up.patient reported

Main Result

Mean Difference: 2.13 (95% CI 0.75–3.51)

p-value: p=0.008 for interaction

Limitations

Older adults in the ISCHEMIA trial may not reflect clinical practice due to exclusion of LVEF ≤35%, eGFR <30 mL/min/1.73 m2, unprotected left main disease ≥50%, severe angina, or recent ACS.
Geriatric-related conditions (frailty, cognitive status, functional independence) were not assessed in the trial or included in adjusted models.
Disproportionally more White participants in the older cohorts, potentially limiting generalizability to older Black, Hispanic, or Asian patients.
Relatively fewer participants at the extremes of age, leading to wider confidence intervals and more uncertainty in estimates among the youngest and oldest patients.
Older adults in the ISCHEMIA trial may not be reflective of older adults in clinical practice due to exclusion of LVEF ≤35%, eGFR <30 mL/min/1.73 m², unprotected left main disease ≥50%, severe angina, or recent ACS.
Geriatric-related conditions (frailty, cognitive status, functional independence) were not assessed in the trial.
Disproportionally more White participants in the older cohorts, limiting generalizability to older Black, Hispanic, or Asian patients.
Relatively fewer participants at the extremes of age, leading to wider confidence intervals in the youngest and oldest patients.

Key expert perspectives

Captured external expert commentary on this paper, strongest first. Original sources are linked where available.

DD Dan D. NguyenCardiologist, Saint Luke's Mid America Heart Institute

“We know from prior observational research that the risks of pursuing revascularization are much higher in older adults. Older adults have a greater risk of acute kidney injury, of major bleeding, and that risk has to be offset with the health status improvement. I think the importance of this paper is that it shows that older adults actually can get some improvements in their health status, but it might not be as much as we thought and that has to be taken into consideration when we decide to refer older adults to invasive management.”

Saint Luke's Mid America Heart InstituteNews Coverage

Implication

In older adults with chronic coronary disease and moderate-to-severe ischemia, an invasive strategy provides consistent relief of angina frequency but smaller improvements in overall angina-related health status and quality of life compared with younger patients, without reducing clinical events.

Abstract

Background:: Whether initial invasive management in older versus younger adults with chronic coronary disease (CCD) and moderate or severe ischemia improves health status or clinical outcomes is unknown. Objectives:: Examine the impact of age on health status and clinical outcomes with invasive versus conservative management in the ISCHEMIA trial. Methods:: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ; score range 0–100; higher=better health status). Cox proportional hazards models estimated the treatment effect of invasive versus conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. Results:: Among 4617 participants, 2239 (48.5%) were <65, 1713 (37.1%) were 65–74, and 665 (14.4%) were ≥75 years old. Baseline SAQ Summary Scores were lower in participants <65 years old. Fully adjusted differences in 1-year SAQ Summary Scores (invasive minus conservative) were 4.90 (95% CI 3.56, 6.24) at age 55, 3.48 (95% CI 2.40, 4.57) at age 65, and 2.13 (95% CI 0.75, 3.51) at age 75 (interaction P=0.008). Improvement in SAQ Angina Frequency was less dependent on age (interaction P=0.07). There were no age differences between invasive versus conservative management on the composite clinical outcome (interaction P=0.29). Conclusions:: Older patients with CCD and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Nguyen et al. (2023) conducted an RCT in Chronic coronary disease with moderate or severe ischemia (n=4,617). Routine invasive management strategy (guideline-directed medical therapy with angiography and revascularization if feasible) vs. Conservative management strategy (guideline-directed medical therapy only, with angiography and revascularization reserved for failure of medical therapy) was evaluated on 1-year angina-specific health status measured by 7-item Seattle Angina Questionnaire (SAQ) Summary Score (at age 75) (MD 2.13, 95% CI 0.75, 3.51, p=0.008 for interaction). Invasive management yielded smaller 1-year SAQ Summary Score gains in older vs younger adults (MD 2.13 at age 75 vs 4.90 at age 55; p-interaction=0.008) with no difference in clinical outcomes.

synapsesocial.com/papers/6adf6e9e47ba7c6662ab3632 https://doi.org/10.1016/j.jacc.2023.02.048

View Full Paper

Ask AI

Bookmark

Share

Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease

Key Points

Study Design

Structured PICO

Main Result

Limitations

Key expert perspectives

Implication

Abstract

Discussion

Cite This Study

Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease

Key Points

Study Design

Structured PICO

Main Result

Limitations

Key expert perspectives

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading