The importance of improving symptoms as well as reducing risk of future adversity.
Buckley et al [1] report important findings for the prognosis of
patients with incident angina in primary care. They write ‘While the
benefit associated with percutaneous transluminal coronary angioplasty in
patients with acute coronary syndromes is established, its value in
patients without these problems is less certain’.
In those patients with exertional angina, it has long been known that
prognosis for myocardial infarction and death is not improved by coronary
revascularisation, from a 2000 meta-analysis of randomised controlled
trials comparing PTCA (percutaneous trans-luminal coronary angioplasty,
balloon angioplasty alone without stenting) with medical treatment alone
[2] to the more recent COURAGE trial.[3]
The importance of revascularisation in improving symptomatic outcomes
has been shown in both meta-analyses [2] and large clinical trials.[3]
Prognostic outcomes in trials examining the impact of revascularisation in
patients with exertional, non-acute angina should include measures of
morbidity, i.e., in the study of symptomatic outcomes, quality of life or
return to work, rather than focussing on myocardial infarction, ‘MACE’ and
death. These outcomes may then reveal surprising differences - we recently
reported that South Asian patients with chronic angina were less likely to
experience long-term improvement in angina following coronary
revascularisation when compared to whites, despite a similar prognosis for
myocardial infarction and death, even after having taken into account
appropriateness for revascularisation and differences in clinical
characteristics. [4]
Patients go to doctors with symptoms. Though they may well ask ‘what
are my chances, doc’, they also want to get rid of those symptoms.
1. Buckley BS, Simpson CR, McLernon DJ, Murphy AW, Hannaford PC. Five
year prognosis in patients with angina identified in primary care:
incident cohort study. BMJ 2009;339(August 6):b3058-.
2. Bucher HC, Hengstler P, Schindler C, Guyatt GH. Percutaneous
transluminal coronary angioplasty versus medical treatment for non-acute
coronary heart disease: meta-analysis of randomised controlled trials. BMJ
2000;321(7253):73-7.
3. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ,
et al. Optimal Medical Therapy with or without PCI for Stable Coronary
Disease. N Engl J Med 2007(March 26, 2007):NEJMoa070829.
4. Zaman MJ, Crook AM, Junghans C, Fitzpatrick NK, Feder G, Timmis
AD, et al. Ethnic differences in long-term improvement of angina following
revascularization or medical management: a comparison between south Asians
and white Europeans. J Public Health (Oxf) 2009;31(1):168-74.
Rapid Response:
The importance of improving symptoms as well as reducing risk of future adversity.
Buckley et al [1] report important findings for the prognosis of
patients with incident angina in primary care. They write ‘While the
benefit associated with percutaneous transluminal coronary angioplasty in
patients with acute coronary syndromes is established, its value in
patients without these problems is less certain’.
In those patients with exertional angina, it has long been known that
prognosis for myocardial infarction and death is not improved by coronary
revascularisation, from a 2000 meta-analysis of randomised controlled
trials comparing PTCA (percutaneous trans-luminal coronary angioplasty,
balloon angioplasty alone without stenting) with medical treatment alone
[2] to the more recent COURAGE trial.[3]
The importance of revascularisation in improving symptomatic outcomes
has been shown in both meta-analyses [2] and large clinical trials.[3]
Prognostic outcomes in trials examining the impact of revascularisation in
patients with exertional, non-acute angina should include measures of
morbidity, i.e., in the study of symptomatic outcomes, quality of life or
return to work, rather than focussing on myocardial infarction, ‘MACE’ and
death. These outcomes may then reveal surprising differences - we recently
reported that South Asian patients with chronic angina were less likely to
experience long-term improvement in angina following coronary
revascularisation when compared to whites, despite a similar prognosis for
myocardial infarction and death, even after having taken into account
appropriateness for revascularisation and differences in clinical
characteristics. [4]
Patients go to doctors with symptoms. Though they may well ask ‘what
are my chances, doc’, they also want to get rid of those symptoms.
1. Buckley BS, Simpson CR, McLernon DJ, Murphy AW, Hannaford PC. Five
year prognosis in patients with angina identified in primary care:
incident cohort study. BMJ 2009;339(August 6):b3058-.
2. Bucher HC, Hengstler P, Schindler C, Guyatt GH. Percutaneous
transluminal coronary angioplasty versus medical treatment for non-acute
coronary heart disease: meta-analysis of randomised controlled trials. BMJ
2000;321(7253):73-7.
3. Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ,
et al. Optimal Medical Therapy with or without PCI for Stable Coronary
Disease. N Engl J Med 2007(March 26, 2007):NEJMoa070829.
4. Zaman MJ, Crook AM, Junghans C, Fitzpatrick NK, Feder G, Timmis
AD, et al. Ethnic differences in long-term improvement of angina following
revascularization or medical management: a comparison between south Asians
and white Europeans. J Public Health (Oxf) 2009;31(1):168-74.
Competing interests:
None declared
Competing interests: No competing interests