Long-Term Survival in Patients With Refractory Angina

Study Questions:

What are the long-term survival and predictors of mortality among patients followed at a dedicated clinic for refractory angina?

Methods:

This was an observational analysis of 1,200 consecutive patients in the prospective clinical database, maintained by the Options in Myocardial Ischemic Syndrome Therapy (OPTIMIST) program at the Minneapolis Heart Institute, for patients with either refractory myocardial ischemia and/or refractory angina considered not to be candidates for traditional revascularization and referred for alternative treatment strategies. Time to death was analyzed using survival analysis methods.

Results:

Median follow-up was 5.1 years, with 176 (14.7%) patients followed for over 9 years. From Kaplan-Meier analysis, mortality was 3.9% (95% confidence interval [CI], 2.8-5.0) at 1 year, 17.5% (95% CI, 15.2-19.9) at 5 years, and 28.4% (95% CI, 24.9-32.0) at 9 years. The following alternative treatment strategies were used: 225 (21.2%) patients had enhanced external counterpulsation; 185 (15.4%) had angiogenesis (protein, gene, or stem cell therapy); 78 (6.5%) had transmyocardial revascularization; and 21 (1.8%) had spinal cord stimulation. Causes of death were predominantly cardiovascular, but noncardiac in approximately 30% of patients.

Conclusions:

The authors concluded that among patients followed in a dedicated refractory angina clinic, mortality was lower than previously reported and 9-year survival was over 70%.

Perspective:

Although there is a paucity of data to guide the care of patients with refractory angina, the reality is that, in an aging population, there will be more patients who will not be considered candidates for traditional revascularization. The limitations of this analysis and the potential for referral bias aside, the results of this study are a valuable description of the long-term follow-up of patients in a dedicated refractory angina clinic. The authors have suggested that mortality in this cohort is surprisingly low, under 4% per year, and that over 70% of patients can expect to survive to 9 years. Therapeutic goals could be framed in the context of this anticipated survival, and should focus on symptomatic relief and improved quality of life.

Clinical Topics: Cardiac Surgery, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Mechanical Circulatory Support

Keywords: Cause of Death, Coronary Artery Disease, Kaplan-Meier Estimate, Survival Analysis, Spinal Cord Stimulation, Counterpulsation, Cell- and Tissue-Based Therapy


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