Abstract 4146729: Residual Angina Following Anatomic Complete Revascularization for Chronic Coronary Disease in the ISCHEMIA Trial: Frequency, Characteristics, and Outcomes

Background: Although residual angina after revascularization for chronic coronary disease (CCD) is common, it is unclear if the cause is incomplete revascularization of epicardial coronary disease or other ischemic mechanisms such as microvascular dysfunction or vasospastic angina. Methods: Among invasively managed ISCHEMIA trial participants with angina at baseline and anatomic complete revascularization (ACR) determined by core lab analysis, the frequency of and characteristics associated with residual angina and its association with health status, medication use at 6 months, and 5-year all-cause and cardiovascular (CV) mortality were assessed. The Seattle Angina Questionnaire Angina Frequency (SAQ AF) was used in a binary fashion to define residual angina as a score <100 at 3 or 6 months, whereas angina-free status was as a SAQ AF = 100 at 3 and 6 months. Results: Of 2,588 participants randomized to the invasive arm, 1,442 had angina at baseline and no prior coronary artery bypass graft surgery, and 1,034 underwent revascularization within 90 days. Among 463 patients in whom ACR was achieved, 436 had SAQ AF scores available at 3 and 6 months. Of these, 184 (42%) had residual angina. Residual angina patients did not differ from those who were angina-free in age (63 + 10 vs. 62 + 10, P=0.37), female sex (33% vs. 27%, P=0.24), hypertension (76% vs. 72%, P=0.33), current smoking (12% vs. 14%, P=0.69), diabetes (41% vs. 41%, P=0.95), ejection fraction (62 + 8 vs. 62 + 8, P=0.98), degree of baseline ischemia, and extent of coronary disease. At baseline, their health status measures including SAQ AF (71 ± 17 vs. 72 ± 118, P= 0.76) were similar. However, at 6 months, patients with residual angina had reduced quality of life (SAQ QoL: 70 + 20 vs. 83 + 20, P<0.001), more physical limitation (SAQ Physical Limitation: 84 + 20 vs. 95 + 11, P<0.001), more dyspnea (Rose Dyspnea Score: 1 + 1.3 vs. 0.4 + 0.8, P<0.001), and were taking more anti-anginal medications (P=0.006). At 5-years, survival free of all-cause or CV death did not differ between groups. Conclusion: Residual angina following ACR for CCD is common and not predicted by any baseline demographic or clinical characteristics. It is associated with reduced QoL and health status despite greater anti-anginal medication use. The high rate of residual angina suggests that alternative mechanisms of ischemia often exist in combination with obstructive coronary disease and contribute to residual anginal symptoms.