Residual Angina Following Complete Revascularization in the ISCHEMIA Trial: Frequency, Clinical Characteristics, Health Status, and Cardiovascular Outcomes

Clinical Snapshot

Key Findings

• P Value: P<0.001 for quality of life and physical limitation differences

• Effect Size: Quality of life difference: 13 points lower (70±20 vs 83±20) on SAQ-QOL scale

• Primary Outcome: 42.2% (184/436) had residual angina within 6 months of complete revascularisation

• Nnt Or Sensitivity: Number needed to harm: approximately 2.4 patients will have residual angina for every complete revascularisation

• Confidence Interval: Not reported in abstract

Clinical Application

Highly feasible - uses standard revascularisation techniques and validated questionnaires available in Australian practice Relevant to Australian cardiology practice; SAQ tools available; findings support need for comprehensive post-revascularisation symptom assessment and management strategies Australian patients with chronic coronary disease undergoing complete revascularisation, particularly those with baseline angina symptoms

Abstract

BACKGROUND: The frequency of residual angina and its impact on health status and death following anatomic complete revascularization in symptomatic patients with chronic coronary disease are unknown. METHODS: Data were analyzed from ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial participants randomized to invasive management with baseline angina (Seattle Angina Questionnaire Angina Frequency score <100), no prior coronary artery bypass graft surgery, and anatomic complete revascularization within 90 days of randomization. The primary outcome was frequency of residual angina after revascularization, defined as a Seattle Angina Questionnaire Angina Frequency score <100 within 6 months of randomization. Secondary outcomes included 6-month health status and medication use and 5-year all-cause and cardiovascular death. RESULTS: Among 2588 participants randomized to invasive management, 1442 (56%) had baseline angina and no prior coronary artery bypass graft surgery; 1034 underwent revascularization within 90 days, and 436 achieved anatomic complete revascularization. Of these, 184 (42.2%) had residual angina within 6 months. Baseline characteristics were similar between those with and without residual angina. Percutaneous coronary intervention was more common than coronary artery bypass graft surgery in those with residual angina (88% versus 80%, P=0.03). At 6 months, residual angina participants reported lower quality of life (Seattle Angina Questionnaire Quality of Life: 70±20 versus 83±20, P<0.001), greater physical limitation (Seattle Angina Questionnaire Physical Limitation: 84±20 versus 95±11, P<0.001), more dyspnea (Rose Dyspnea Scale score: 1±1.3 versus 0.4±0.8, P<0.001), and more antianginal medication use (P=0.006). Five-year all-cause and cardiovascular death did not differ significantly between groups. CONCLUSIONS: Residual angina is common (>40%) following anatomic complete revascularization for chronic coronary disease and is associated with reduced quality of life and greater antianginal medication use but no increase in death. REGISTRATION: Unique Identifier: NCT01471522.

References

1. 1.Singh, A., Brown, D. L., Jones, P. G., Fu, Z., Reynolds, H. R., Boden, W. E., O'Brien, S. M., Mavromatis, K., Poh, K. K., Ali, Z., Stone, G. W., Bangalore, S., Spertus, J. A., Maron, D. J., & Hochman, J. S. (2026). Residual angina following complete revascularization in the ISCHEMIA trial: Frequency, clinical characteristics, health status, and cardiovascular outcomes. Journal of the American Heart Association, Article e047355. https://doi.org/10.1161/JAHA.125.047355