BACKGROUND: Although angina is common in patients with stable coronary artery disease (CAD), limited data are available on its prevalence, natural evolution, and outcomes in the era of effective cardiovascular drugs and widespread use of coronary revascularization.
METHODS: Using data from 32 691 patients with stable CAD from the prospective observational CLARIFY registry, anginal status was mapped each year in patients without new coronary revascularization or new myocardial infarction. The use of medical interventions in the year preceding angina resolution was explored. The effect of 1-year changes in angina status on 5-year outcomes was analyzed using multivariable analysis.
RESULTS: Among 7212 (22.1%) patients who reported angina at baseline, angina disappeared (without coronary revascularization) in 39.6% at 1 year, with further annual decreases. In patients without angina at baseline, 2.0–4.8% developed angina each year. During 5-year follow-up, angina was controlled in 7773 patients, in whom resolution of angina was obtained with increased use of antianginal treatment in 11.1%, with coronary revascularization in 4.5%, and without any changes in medication or revascularization in 84.4%. Compared to patients without angina at baseline and 1 year, persistence of angina and occurrence of angina at 1 year with conservative management were each independently associated with higher rates of cardiovascular death or myocardial infarction (adjusted hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.12−1.55 for persistence of angina; adjusted HR 1.37, 95% CI 1.11−1.70 for occurrence of angina) at 5 years. Patients whose angina had resolved at 1 year with conservative management were not at higher risk of cardiovascular death or myocardial infarction than those who never experienced angina (adjusted HR 0.97, 95% CI 0.82−1.15).
CONCLUSIONS: Angina affects almost one-quarter of patients with stable CAD but resolves spontaneously in most patients. Resolution of angina within 1 year with conservative management predicted outcomes similar to lack of angina, while persistence or occurrence was associated with poor outcomes. As most patients have no angina and those with angina are likely to experience resolution of symptoms, and as there is no demonstrated outcome benefit to routine revascularization, this study emphasizes the value of conservative management of stable CAD.