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Post-MI angina in stable patients flags high risk

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Angina in stable post-MI patients poses a new, adverse scenario

This analysis of data collected in the CLARIFY registry introduces a new scenario that may be of interest: Post-MI patients who develop angina. However, this registry comes with several caveats. Most importantly, the endpoints recorded in the CLARIFY registry were based on predefined events that did not undergo routine adjudication. Cardiovascular disease death is hard to identify, and only 1% of events underwent an audit. It is also hard to contextualize the findings as no other randomized trial or registry has enrolled an entirely similar population. The patients enrolled in CLARIFY show the diversity of patients who fall under the new category recently defined by a task force of the European Society of Cardiology: chronic coronary syndromes (Eur Heart J. 2019 Aug 31. doi: 10.1093/eurheartj/ehz425).

Dr. David Hasdai, Rabin Medical Center, Petah Tikva, Israel Mitchel L. Zoler/MDedge News

Dr. David Hasdai

Perhaps the biggest uncertainty about the findings from the CLARIFY registry is how angina at baseline in post-MI patients exerts an effect on cardiovascular death or recurrent nonfatal MI as long as 5 years later. Potentially more relevant and more objective markers to look at would be persistent angina and ischemia. The registry collected data on ischemia, and it makes sense to prefer this measure over the more subjective patient report of angina. The findings also raise questions about the treatments that individual patients received for their angina and the impact these interventions may have had, as well as about the origin of the angina and whether it may have been treatment related.

David Hasdai, MD , is professor of medicine at Rabin Medical Center in Peta Tikva, Israel. He had no disclosures. He made these comments as designated discussant for the CLARIFY report.


 

REPORTING FROM THE ESC CONGRESS 2019

– Patients with angina who were also more than 3 months out from a prior MI had a significantly increased rate of subsequent cardiovascular death or nonfatal MI in a study of nearly 33,000 patients, a finding that identified angina as a new red flag when following post-MI patients.

Dr. Emmanuel Sorbets, Avicenne Hospital, Bobigny, France Mitchel L. Zoler/MDedge News

Dr. Emmanuel Sorbets

“Angina and prior MI was a higher-risk subgroup that may warrant more intensive management. This is new,” Emmanuel Sorbets, MD, said at the annual congress of the European Society of Cardiology.

The finding came from review of 32,703 patients from 45 countries with stable coronary artery disease enrolled in the CLARIFY (Prospective Observational Longitudinal Registry of Patients with Stable Coronary Artery Disease) registry during 2009-2010, a population that appeared to uniformly meet the new definition of chronic chromic syndromes recently published by a task force of the society (Eur Heart J. 2019 Aug 31. doi: 10.1093/eurheartj/ehz425).

Among the CLARIFY patients, 60% had an MI more than 3 months prior to enrollment (the registry excluded patients with more proximate MIs), and in this subgroup angina at baseline was linked with a 3.6% absolute increase in the rate of cardiovascular death or nonfatal MI compared with post-MI patients without angina at baseline during a median 5 year follow-up. This translated into a 44% relative increase that remained statistically significant after adjustment for several demographic and clinical factors, said Dr. Sorbets, a cardiologist at Avicenne Hospital in Bobigny, France. The cumulative incidence of the combined endpoint was 11.8% among post-MI patients with baseline angina and 8.2% in those without angina. Among patients without a prior MI, the presence or absence of angina at entry into the registry had no link with the incidence of later outcomes. Concurrently with Dr. Sorbets’ report at the congress, the results appeared in an article published online (Eur Heart J. 2019 Sep 3;doi: 10.1093/eurheartj/ehz660).

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This finding should immediately influence practice, said Sanjay Sharma, MD, professor of inherited cardiac diseases and sports cardiology at St. George’s University, London. “One of the messages from this study is that we now have a very easy way to measure a high-risk factor,” and that patients who present with angina more than 3 months after an MI “require intensive investigation and aggressive management,” he said. The new evidence identified post-MI patients with angina as having a “semi-urgent” condition that needs added anti-anginal treatment and, if symptoms persist, possible revascularization, especially patients without prior revascularization, he said in a video interview. Although the study did not analyze the type of MI linked with these poor outcomes, Dr. Sharma speculated that certain patients with a prior non ST-elevation MI may face the greatest danger it they did not undergo percutaneous coronary revascularization at the time of their MI.

CLARIFY is sponsored by Servier. Dr. Sorbets has received personal fees from Servier, AstraZeneca, Bayer, Bristol-Myers Squibb, Merck Sharpe & Dohme, and Novartis. Dr. Sharma had no relevant disclosures.

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