Elsevier

American Heart Journal

Volume 146, Issue 6, December 2003, Pages 1015-1022
American Heart Journal

Clinical investigations
Anginal symptoms consistently predict total mortality among outpatients with coronary artery disease

Presented at the American Heart Association Conference on Cardiovascular Disease Epidemiology and Prevention, Miami, Fla, March 5−8, 2003.
https://doi.org/10.1016/S0002-8703(03)00436-8Get rights and content

Abstract

Background

Age, race, education, and diabetes have been associated with differences in anginal symptoms, treatments, and outcomes among outpatients with coronary artery disease (CAD), but there is little data on whether such characteristics affect relationships between anginal symptoms and mortality.

Methods

Using a prospective cohort design, we examined associations of anginal symptoms, as assessed by the Seattle Angina Questionnaire, with total mortality among 8908 outpatients with CAD to investigate whether this relationship is influenced by patient demographic or clinical characteristics. Potential effect modification was primarily assessed for age, race, education, and diabetes, and secondarily assessed for smoking, prevalent congestive heart failure (CHF), myocardial infarction, and coronary revascularization.

Results

Over 2 years mean follow-up, there were 896 deaths. After adjustment for potential confounders, persons reporting greater physical limitation due to angina had higher mortality: 27% higher with mild limitation (hazard ratio [HR] 1.27, 95% CI 0.98–1.64), 61% higher with moderate limitation (HR 1.61, 95% CI 1.27–2.05), and 2.5-fold higher with the greatest limitation (HR 2.55, 95% CI 1.97–3.30), compared with little or no limitation (P for trend <.001). Anginal instability was also independently predictive of mortality. There was little evidence that these relationships varied by age, race, education, diabetes, smoking, or presence of CHF, prior myocardial infarction, or prior coronary revascularization (P for each interaction >.28). Anginal symptoms predicted higher mortality risk comparable to a decade of age difference, presence of diabetes, or presence of CHF.

Conclusions

Among outpatients with CAD, self-reported anginal symptoms consistently predict mortality irrespective of differences in age, race, education, or clinical comorbidities.

Section snippets

Study design and population

These analyses used prospectively collected data from ACQUIP. The goal, design and components of the trial have been summarized previously.25 The protocol was approved by the institutional review board of each center, and all subjects gave informed written consent. Between January 1997 and March 2000, all outpatients assigned a primary provider and seen in the last year at the general internal medicine clinics at 7 Veterans Affairs Medical Centers (Birmingham, Little Rock, Richmond, San

Patient population

Selected baseline characteristics are shown overall and according to physical limitation due to angina (Table I). Average age at baseline was 67.6 years. As expected for a population of veterans with CAD, 98.3% were male. One third were nonwhite, and one quarter had diabetes. Approximately 1 in 5 participants had clinical CHF, nearly half reported prior coronary revascularization, and nearly half reported prior MI. Characteristics of persons excluded due to missing SAQ information were

Discussion

We observed a strong, graded, and independent relationship between anginal symptoms, as assessed by the SAQ, and total mortality among these outpatients with CAD. These results confirm the previously observed relationship between anginal symptoms and mortality seen at 1 year among a subset of these participants.12 More importantly, these findings extend the prior report by demonstrating that self-reported anginal symptoms—specifically, physical limitation due to angina and anginal

Acknowledgements

Support for Drs Bryson and Mozaffarian was provided by Veterans Affairs Health Services Research & Development fellowships at the Veterans Affairs Puget Sound Health Care System.

References (31)

Cited by (0)

Drs Bryson and Mozaffarian contributed equally to this work.

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