A new study finds that an invasive approach results in smaller improvements in angina-related health status and quality of life (QOL) among older patients with chronic coronary disease (CCD) and ischemia. When compared to younger patients, the trial, which used the Seattle Angina Questionnaire (SAQ), found that fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative management) were 4.90 (95% confidence interval [CI]: 3.56 to 6.24) in patients at age 55 years. SAQ summary scores for patients at age 65 years were 3.48 (95% CI: 2.40 to 4.57), and 2.13 (95% CI: 0.75 to 3.51) at age 75 years (P interaction = 0.008) with higher scores indicating better health status. “The benefits of an invasive strategy in reducing angina and improving physical function were similar in older and younger patients,” said the study published Monday online and in the May 2issue of the Journal of the American College of Cardiology. “The importance of these benefits might be less critical to older patients who may have fewer physical demands and are more readily able to adapt to angina than younger patients, thus resulting in less difference in QOL between the two treatment strategies in older patients.” Further findings revealed that invasive management was not linked with improved clinical outcomes in older or younger patients with improvement in SAQ Angina Frequency less dependent on age. Study approach The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial adopted a randomized, parallel-assignment, unblinded format. Among the 4,617 participants taking part, 2,239 (48.5%) were aged <65 years, and 22.4% were female with 19.6% experiencing a prior myocardial infarction (MI). A total of 1,713 (37.1%) patients aged 65 to 74 years were also enrolled, with 22.7% female and 22.0% experiencing a prior MI. The final group consisted of 665 (14.4%) patients aged ≥75 years. Here, 27.5% were female and 20.9% experienced a prior MI. Median age was 65 years (interquartile range [IQR]: 59-71 years). The seven-item SAQ was carried out before randomization and at 1.5, 3 and 6 months, and then every 6 months thereafter until the trial was completed. Primary clinical outcomes of the trial was the composite of cardiovascular death, nonfatal MI or hospitalization for heart failure, unstable angina or resuscitated cardiac arrest. Along with the SAQ summary scores, results over a median follow-up of 3.2 years (IQR: 2.2 to 4.4 years), found the cumulative event rate for the primary clinical outcome was 12.5% in participants aged <65 years, 15.0% in participants aged 65 to 74 years, and 21.1% in participants aged ≥75 years. Further findings In unadjusted analyses, compared with participants aged <65 years, participants aged 65 to 74 years had a >20% increased risk of experiencing the primary clinical outcome (hazard ratio [HR]: 1.24; 95% CI: 1.04 to 1.49). Participants aged ≥75 years had an almost twofold increased risk (HR: 1.95; 95% CI: 1.58 to 2.41) of experiencing the primary outcome (P < 0.001). The risk of cardiovascular death, nonprocedural MI, hospitalization for heart failure, and stroke also increased with increasing age, but the risk of procedural MI did not, the study said. Commenting on the findings, the research team, led by Dan D. Nguyen, MD, from Saint Luke’s Mid America Heart Institute in Kansas City, Missouri, said angina relief should be considered along with other health status outcomes, including physical functioning and QOL, particularly in older adults. “Careful consideration (and if possible, quantification with the SAQ) of anginal symptoms, physical functioning, and QOL could be used to align treatment decisions with care goals. “Moreover, geriatric-centric factors such as cognitive function, frailty, and independence can influence clinical and health status outcomes and should be considered as additional factors for such risk models and shared decision making tools.” ‘Landmark contribution to existing literature’ In an accompanying editorial by Parag Goyal, MD from Weill Cornell Medicine in New York, and Michael G. Nanna, MD from the Yale School of Medicine in New Haven, Connecticut, the authors described the trial as a “landmark contribution to the existing literature.” “The authors should be applauded for improving our understanding of the impact of an invasive vs conservative management strategy on symptoms, function, and quality of life in older adults.” The authors added that while older adults achieved improvements in angina-related health status and overall QOL regardless of strategy, the findings indicated that managing stable CAD in older adults was possible. The approach here would be a preference-sensitive decision that thus requires careful deliberation and patient involvement, they said. Sources: Nguyen DD, Spertus JA, Alexander KP, et al. Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial. J Am Coll Cardiol. 2023;81:1697–1709. Goyal P, Nanna MG. Stable Coronary Artery Disease in the Age of Geriatric Cardiology. J Am Coll Cardiol. 2023;81:1710–1713. Image Credit: Vadi Fuoco – stock.adobe.com