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Figure.  Physician-Estimated Canadian Cardiovascular Society (CCS) Class vs Seattle Angina Questionnaire (SAQ) Angina Frequency Scores in Patients Undergoing Percutaneous Coronary Intervention for Stable Ischemic Heart Disease and Unstable Angina
Physician-Estimated Canadian Cardiovascular Society (CCS) Class vs Seattle Angina Questionnaire (SAQ) Angina Frequency Scores in Patients Undergoing Percutaneous Coronary Intervention for Stable Ischemic Heart Disease and Unstable Angina

CAD indicates coronary artery disease.

Table.  CCS Classification vs SAQ AF Scores in Patients Undergoing Percutaneous Coronary Intervention for Stable Ischemic Heart Disease and Unstable Angina
CCS Classification vs SAQ AF Scores in Patients Undergoing Percutaneous Coronary Intervention for Stable Ischemic Heart Disease and Unstable Angina
1.
Weintraub  WS, Spertus  JA, Kolm  P,  et al; COURAGE Trial Research Group.  Effect of PCI on quality of life in patients with stable coronary disease.   N Engl J Med. 2008;359(7):677-687. doi:10.1056/NEJMoa072771 PubMedGoogle ScholarCrossref
2.
Patel  MR, Calhoon  JH, Dehmer  GJ,  et al.  ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons.   J Am Coll Cardiol. 2017;69(17):2212-2241. doi:10.1016/j.jacc.2017.02.001 PubMedGoogle ScholarCrossref
3.
Arnold  SV, Grodzinsky  A, Gosch  KL,  et al.  Predictors of physician under-recognition of angina in outpatients with stable coronary artery disease.   Circ Cardiovasc Qual Outcomes. 2016;9(5):554-559. doi:10.1161/CIRCOUTCOMES.116.002781 PubMedGoogle ScholarCrossref
4.
Arnold  SV, Kosiborod  M, Li  Y,  et al.  Comparison of the Seattle Angina Questionnaire with daily angina diary in the TERISA clinical trial.   Circ Cardiovasc Qual Outcomes. 2014;7(6):844-850. doi:10.1161/CIRCOUTCOMES.113.000752 PubMedGoogle ScholarCrossref
5.
Campeau  L.  Letter: grading of angina pectoris.   Circulation. 1976;54(3):522-523. doi:10.1161/circ.54.3.947585 PubMedGoogle ScholarCrossref
6.
Spertus  JA, Jones  PG, Maron  DJ,  et al; ISCHEMIA Research Group.  Health-status outcomes with invasive or conservative care in coronary disease.   N Engl J Med. 2020;382(15):1408-1419. doi:10.1056/NEJMoa1916370PubMedGoogle ScholarCrossref
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    Research Letter
    Cardiology
    June 19, 2020

    Comparison of Patient-Reported vs Physician-Estimated Angina in Patients Undergoing Elective and Urgent Percutaneous Coronary Intervention

    Author Affiliations
    • 1St Luke’s Mid America Heart Institute, Kansas City, Missouri
    • 2University of Missouri-Kansas City, Kansas City, Missouri
    JAMA Netw Open. 2020;3(6):e207406. doi:10.1001/jamanetworkopen.2020.7406
    Introduction

    Coronary revascularization in stable ischemic heart disease (SIHD) is indicated for angina relief.1,2 In practice, the Canadian Cardiovascular Society (CCS) classification is used to quantify angina. However, this classification is a physician’s estimate of angina rather than a patient-reported measure, and there is evidence of discordance between these measures.3 Whether discordance between physician-assessed and patent-reported angina exists in patients undergoing percutaneous coronary intervention (PCI) is unclear. Therefore, we compared these measures in a cohort of patients undergoing PCI.

    Methods

    This cohort study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The institutional review board of Saint Luke’s Mid America Heart Institute approved the study, and the institutional review boards of the participating medical centers (eAppendix in the Supplement) waived the requirement for patient written informed consent because this study’s analyses were done within a study to improve the process of informed consent; this study was deemed a quality improvement initiative. Data were collected from April 13, 2009, to October 31, 2011, and were analyzed from November 20, 2019, to March 4, 2020.

    We used the Seattle Angina Questionnaire (SAQ) to collect patient-reported angina and the CCS classification for physicians’ estimates of angina from 10 medical centers that were part of the Patient Risk information Services Manager study between 2009 and 2011 (eAppendix in the Supplement). The CCS class was obtained from the National Cardiovascular Data Registry record. The SAQ angina frequency (AF) domain (scores of 0-30, 31-60, 61-99, and 100 representing daily, weekly, monthly, and no symptoms of angina, respectively) was used to assess the burden and frequency of angina over the previous 4 weeks (eAppendix in the Supplement) and the score correlates closely with daily angina diaries.4 The CCS classification was used to stratify angina into levels 0 to IV, with higher classes corresponding with increasing symptom burden.5

    Results

    This cohort study included 759 patients who underwent PCI for SIHD, and 895 who underwent PCI for unstable angina. Mean (SD) patient age was 64.3 (10.7) years, 71% were men, 44.4% had a prior PCI, and 21.7% had a prior coronary artery bypass grafting procedure. For patients treated for SIHD, 267 of 759 (35.2%) had an SAQ-AF score of 100 (no angina). Of these patients, 33 (12.4%) and 20 (7.5%) were classified by physicians as having moderate (CCS class II) or severe (CCS class III-IV) angina, respectively (Table, Figure). For patients with unstable angina, 110 of 895 (12.3%) had an SAQ AF of 100. Of these patients, 12 (10.9%) were categorized by physicians as having moderate symptoms, and 39 patients (35.5%) were categorized has having severe symptoms (Table, Figure).

    Discussion

    Although validated patient-reported instruments are available, angina assessment in clinical practice relies on physicians’ estimates. We found that 35.5% of patients undergoing PCI for SIHD and 12.3% of those with unstable angina reported no angina within 4 weeks. However, many of these patients were categorized by physicians as having moderate or severe symptoms. These findings build on studies showing discordance between assessments of health status3 and suggest that patients’ reports of angina symptoms may be more relevant than physician’s estimates. As new data emerge from studies such as ISCHEMIA6 and highlight the limited benefits of revascularization in asymptomatic patients, it is increasingly important to directly elicit patients’ experiences.

    This study has limitations. First, data were collected 9 years ago, although there is no reason to expect patterns of angina assessment would have changed substantially over time. Second, patients with unstable angina typically have recent symptom onset (eg, within 24 hours), and the SAQ is designed to assess symptoms over the last 4 weeks. Third, physicians’ estimates of unstable angina may also be inaccurate in an era of Appropriate Use Criteria in which higher ratings for are assigned for unstable angina than for SIHD. Fourth, we cannot exclude the possibility that some patients had atypical presentations that were not captured by the SAQ; whether other instruments, including the Rose Dyspnea Score, may be more sensitive to atypical angina is unknown. In addition, we did not assess angina at follow-up; thus, conclusions regarding the best method of assessment at baseline could not be drawn from the context of this study.

    In this cohort study, 35.5% of patients undergoing PCI for SIHD and 12.3% of those undergoing PCI for unstable angina self-reported no angina. Among patients without self-reported angina, 1 in 5 undergoing elective PCI and 1 in 2 undergoing urgent PCI were assessed by physicians to have moderate-to-severe angina. These data have important implications for patient selection for coronary revascularization.

    Back to top
    Article Information

    Accepted for Publication: April 5, 2020.

    Published: June 19, 2020. doi:10.1001/jamanetworkopen.2020.7406

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Saxon JT et al. JAMA Network Open.

    Corresponding Author: John T. Saxon, MD, St Luke’s Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO 64111 (jsaxon@saint-lukes.org).

    Author Contributions: Drs Saxon and Spertus had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Saxon, Tran, Spertus.

    Acquisition, analysis, or interpretation of data: Chan, Tran, Angraal, Jones, Grantham, Spertus.

    Drafting of the manuscript: Saxon, Tran, Angraal, Grantham.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Saxon, Tran, Jones.

    Obtained funding: Spertus.

    Administrative, technical, or material support: Angraal, Grantham, Spertus.

    Supervision: Spertus.

    Conflict of Interest Disclosures: Dr Saxon reported receiving honoraria from Abbott Vascular. Dr Chan reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study and consultant fees from American Heart Association outside the submitted work. Dr Grantham reported receiving personal fees from Corindus Medical, grants and personal fees from Boston Scientific, personal fees from Abbott Vascular; honoraria from Boston Scientific, Abbott Vascular, Vascular Solutions, and Asahi Intecc; a grant from Boston Scientific; stock in Corindus Medical Vascular Robotics and Insysiv; and is a part-time employee of Corindus Medical. Dr Spertus owns the copyright to the Seattle Angina Questionnaire; reported receiving a research contract from the American College of Cardiology Foundation; serving as a member of the scientific advisory board for United Healthcare and the Board of Directors for Blue Cross Blue Shield of Kansas City; consulting fees from Bayer, Amgen, Novartis, Merck, AstraZeneca, Myokardia, and Janssen; and has equity in Health Outcomes Sciences. No other disclosures were reported.

    References
    1.
    Weintraub  WS, Spertus  JA, Kolm  P,  et al; COURAGE Trial Research Group.  Effect of PCI on quality of life in patients with stable coronary disease.   N Engl J Med. 2008;359(7):677-687. doi:10.1056/NEJMoa072771 PubMedGoogle ScholarCrossref
    2.
    Patel  MR, Calhoon  JH, Dehmer  GJ,  et al.  ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons.   J Am Coll Cardiol. 2017;69(17):2212-2241. doi:10.1016/j.jacc.2017.02.001 PubMedGoogle ScholarCrossref
    3.
    Arnold  SV, Grodzinsky  A, Gosch  KL,  et al.  Predictors of physician under-recognition of angina in outpatients with stable coronary artery disease.   Circ Cardiovasc Qual Outcomes. 2016;9(5):554-559. doi:10.1161/CIRCOUTCOMES.116.002781 PubMedGoogle ScholarCrossref
    4.
    Arnold  SV, Kosiborod  M, Li  Y,  et al.  Comparison of the Seattle Angina Questionnaire with daily angina diary in the TERISA clinical trial.   Circ Cardiovasc Qual Outcomes. 2014;7(6):844-850. doi:10.1161/CIRCOUTCOMES.113.000752 PubMedGoogle ScholarCrossref
    5.
    Campeau  L.  Letter: grading of angina pectoris.   Circulation. 1976;54(3):522-523. doi:10.1161/circ.54.3.947585 PubMedGoogle ScholarCrossref
    6.
    Spertus  JA, Jones  PG, Maron  DJ,  et al; ISCHEMIA Research Group.  Health-status outcomes with invasive or conservative care in coronary disease.   N Engl J Med. 2020;382(15):1408-1419. doi:10.1056/NEJMoa1916370PubMedGoogle ScholarCrossref
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