Stable angina: conserv rx more days not in hospital

 A recent secondary analysis of the ISCHEMIA trial found that conservative management of stable angina found that the average number of days alive and not in the hospital was higher than with invasive management (see cad stable ischemia trial jamacard2021 in dropbox, or doi:10.1001/jamacardio.2021.1651)

 

Details:

-- 5179 patients enrolled in the ISCHEMIA trial were assessed for the prespecified analysis of days alive out of hospital (DAOH), which includes both death and days out of the hospital collectively

-- patients had stable coronary disease with moderate or severe ischemia, randomized to invasive vs conservative management (angiography/revascularization vs meds, with both groups receiving optimal medical therapy)

-- see http://gmodestmedblogs.blogspot.com/2020/05/ischemia-trial-stable-angina-conserv.html for details of the study

Results:

-- DAOH at one month, comparing conservative vs invasive management: 30.8 vs 28.4 days, p<0.001

-- DAOH at one year: 362.2 vs 355.9 days, p<0.001

-- DAOH at 2 years: 718.4 vs 712.1 days, p=0.001

-- DAOH at 4 years: 415.0 vs 412.2 days, p=0.65, no longer statistically significant

 

-- there were more hospital and extended care stays in the invasive management vs conservative group during follow-up (4002 vs 1897, p<0.001); excluding protocol-assigned procedures (cath, percutaneous interventions, CABG), however, there were fewer stays in the invasive group: 1568 vs 1897 days, p=0.001, largely related to decreases in MI and unstable angina during follow-up

    -- in the invasive management group, 2434 of the 4002 stays (60.8%) were for the protocol-assigned procedures, largely explaining the differences in DAOH

-- more patients had 0 stays in the conservative group (409 [20%)] vs 1635 [80%], p<0.001) and recurrent stays were also lower in the conservative group (446 [17% ] vs957 [37%])

 

Commentary:

-- the ISCHEMIA trial found that after a median 3.2 years, the invasive management strategy did not reduce the composite primary endpoint of cardiovascular mortality, MI, hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, but it did lessen the occurrence of angina. Prior trials found similar results, such as the COURAGE trial (see cad COURAGEtrial nejm2007 in dropbox, or doi.10.1056/NEJMoa070829)

    -- for the details of the ISCHEMIA trial, its overall conclusions, limitations, and implications, see http://gmodestmedblogs.blogspot.com/2020/05/ischemia-trial-stable-angina-conserv.html

    -- for details on the subgroup with advanced kidney disease, also finding conservative management was better, see http://gmodestmedblogs.blogspot.com/2020/05/ischemia-subtrial-for-ckd-patients.html

-- it is not surprising that several years after the trial, there were increased numbers of hospital days for those on conservative management, but:

    -- as in the COURAGE trial as well, medical management does not do so well for those with angina not responsive to medical therapy. The presence of severe anginal symptoms is complex and involves higher degrees of arterial stenosis. Stable coronary artery disease is typically associated with lesser degrees of stenosis (half of the patients have less than 50% stenosis, as elaborated in the above blog on the ISCMEMIA trial), where the pathology is more inflammatory vulnerable plaques being more susceptible to plaque rupture and thrombotic occlusion of the arteries/acute coronary syndromes.

    -- And, in the ISCHEMIA trial there were greater improvements in the angina-related health status in those with invasive management.

    -- However, there are many advantages to decreasing hospital stays early on, when patients are at a younger age, even if there is no difference in the long run. For example, studies in older patients have found that many patients prioritize time spent at home with family. Earlier time at home is likely to optimize non-hospitalization time when patients have fewer medical comorbidities and a higher quality of life. And, more patients on medical management are likely not to need anything in the medium-term as noted above.

       -- and, the usual admonition: being in the hospital has its own dangers, including close quarters with malevolent microorganisms and nosocomial infections, getting incorrect medications or not getting needed ones, etc.

-- Also, this ISCHEMIA study did not simply compare intensive medical management with interventional strategy itself, but the latter along with intensive medical management (ie, intensive medical management is needed for all). So, one could argue based on the ISCHEMIA study that the baseline intervention for patients with chronic stable angina is intensive medical management, and that some may need subsequent cardiac interventions if they have inadequate anginal symptomatic control.

 

So,  another analysis confirming the appropriateness of intensified medical management in patients with stable angina from coronary artery disease: this is most often just a medical problem...

geoff

 

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