Conference Coverage

Antianginal agents underutilized after MI



– Non–beta-blocker antianginal drugs are seriously underprescribed in patients with angina following percutaneous coronary intervention (PCI) for a myocardial infarction (MI), according to a large national study, Alexander C. Fanaroff, MD, said at the annual meeting of the American College of Cardiology.

Clinical practice in this regard appears to be largely out of touch with current evidence-based guidelines regarding angina management in patients with stable ischemic heart disease. Those ACC/American Heart Association guidelines recommend a stepwise approach beginning with a beta-blocker and sublingual nitroglycerin, adding a calcium channel blocker if the beta-blocker isn’t tolerated or effective, further adding a long-acting nitrate if symptoms persist, incorporating ranolazine (Ranexa) as needed, and finally turning to revascularization for symptomatic relief if multidrug therapy proves inadequate (J Am Coll Cardiol. 2012 Dec 18;60[24]:e44-e164).

Dr. Alexander C. Fanaroff Bruce Jancin/Frontline Medical News

Dr. Alexander C. Fanaroff

That treatment protocol was followed infrequently in the TRANSLATE-ACS (Treatment With Adenosine Diphosphate [ADP] Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study, reported Dr. Fanaroff of the Duke Clinical Research Institute in Durham, N.C.

“When you ask patients and physicians separately about the prevalence of angina, they tend to disagree, with physicians consistently thinking their patients have less angina than patients report themselves. Together, with our data, this indicates that strategies to improve clinician recognition and treatment of angina symptoms are needed,” he asserted.

TRANSLATE-ACS was a large, longitudinal, observational study of patients who underwent PCI at 233 U.S. hospitals during 2010-2012. Dr. Fanaroff focused on 12-month follow-up data on the 10,870 patients whose PCI was for treatment of an acute MI. In telephone interviews 6 weeks postdischarge which incorporated the validated Seattle Angina Questionnaire, 3,190 of these individuals (31%) with stable ischemic heart disease reported angina symptoms. Of those, 79% said their symptoms occurred at least monthly, 18% weekly, and 3% daily. Yet, only 1 in 5 patients with angina 6 weeks postdischarge were on a non–beta-blocker antianginal medication: 16% were on monotherapy with a calcium channel blocker or long-acting nitrate, 3% were on dual therapy, and less than 1% were on three non–beta-blockers for their angina.

The prevalence of angina dropped over time. At 6 months postdischarge, 40% of the original cohort of patients who had angina at 6 weeks still reported angina. At 12 months, it was 33%. Meanwhile, the use of non–beta-blocker antianginal agents crept up modestly over time, from 20% in patients with angina at 6 weeks postdischarge, to 22% in those with angina at 6 months, and 23% at 12 months.

On the other hand, 33% of patients with angina at 6 weeks had persistent angina through 12 months. Remarkably, 69% of these individuals never received a non–beta-blocker antianginal drug during all that time, including 61% of those who experienced daily or weekly angina.

The use of non–beta-blocker antianginal drugs was more frequent in patients with more severe angina: 25% of patients with daily or weekly angina at 6 weeks were on such medication, as were 34% at 6 months and 38% at 12 months, compared with 16%, 18%, and 22% of those with monthly angina. Still, most of these patients were on only a single non–beta-blocker antianginal agent.

Of patients with angina at 6 weeks, 12% subsequently underwent repeat PCI at some point during the first year postdischarge. Of these individuals, 19% were on a single non–beta-blocker antianginal drug at the time of their procedure, 6% were on two such drugs, and only 1% were on three.

Roughly 10% of patients with multivessel coronary disease who were identified angiographically at the time of their acute MI did not undergo multivessel PCI at that time. This was not predictive of angina 6 weeks post discharge, Dr. Fanaroff continued.

One audience member asked Dr. Fanaroff how he knows that the patients with self-reported angina didn’t actually have noncardiac chest pain, in which case their physicians’ decision not to prescribe second- and third-tier antianginal drugs would be appropriate.

Dr. Fanaroff responded that it’s possible, and even likely, that some patients with self-reported angina had a noncardiac source of their chest pain. However, they would be in the minority. The fact is that multiple studies have shown that patients who report experiencing angina after PCI for acute MI have about a 1.5-times increased risk of readmission and repeat revascularization, a 2-times increased risk of developing new depressive symptoms, and diminished quality of life scores.

The TRANSLATE-ACS study was sponsored by Eli Lilly. Dr. Fanaroff reported having no financial conflicts.

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