Prevalence of Anginal Symptoms and Myocardial Ischemia and Their Effect on Clinical Outcomes in Outpatients With Stable Coronary Artery Disease: Data From the International Observational CLARIFY Registry

Study Questions:

Among patients with stable coronary artery disease (CAD), what is the association of anginal symptoms or myocardial ischemia with clinical outcomes?


The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) was a large prospective registry of outpatients with stable CAD. Consecutive patients were enrolled in 45 countries from 2009 to 2010. On the basis of physician-reported symptoms and noninvasive testing for myocardial ischemia, patients were categorized into one of the following: no angina or ischemia, evidence of myocardial ischemia without angina, anginal symptoms alone, and angina and ischemia. The outcome of interest was a composite of cardiovascular (CV)-related death or nonfatal myocardial infarction. Outcome events were not adjudicated (i.e., based on investigator reporting).


The analytic sample included 32,105 patients with a median follow-up of 24.1 months. 70.4% of events occurred in patients without evidence of ischemia. In adjusted analyses, the primary outcome was not more frequent in patients with ischemia alone, compared to those without angina or ischemia (adjusted hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.68-1.20; p = 0.47). However, there was an increased risk in those with angina alone (adjusted HR, 1.45; 95% CI, 1.08-1.95; p = 0.01), and in patients with both angina and ischemia (adjusted HR, 1.75; 95% CI, 1.34-2.29; p < 0.001).


In a large and contemporary observational registry of outpatients with stable CAD, anginal symptoms, but not ischemia alone, were associated with adverse outcomes.


This is an important study that characterizes outcomes in patients with stable CAD in a contemporary registry. It is notable that approximately 70% of events occurred in those without ischemia on noninvasive testing, potentially emphasizing the importance of optimal medical therapy in stable CAD patients, irrespective of symptoms or ischemia. Angina was associated with adverse outcomes in this registry; however, as the authors indicate, those with angina in the CLARIFY registry may have been particularly high risk, perhaps ineligible for revascularization because of underlying illnesses or perhaps having symptoms despite revascularization.

Clinical Topics: Atherosclerotic Disease (CAD/PAD)

Keywords: Prevalence, Coronary Artery Disease, Myocardial Infarction, Outpatients

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