While clinical trials typically report average health outcomes at specific time points, a new secondary analysis of the ISCHEMIA trial has delved into the individual patient journeys of angina symptoms over time. The study identified six distinct patterns of angina trajectories, revealing that an initial invasive strategy is associated with more favourable symptom pathways compared to a conservative approach in patients with chronic coronary disease.¹
This analysis utilised data from the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA; NCT01471522), a randomised trial that originally compared health status outcomes between invasive and conservative care.² The cohort for this analysis included 2,977 participants with chronic coronary disease, moderate-to-severe ischaemia, and baseline angina, who were enrolled between 2012 and 2018.
Participants were randomised to either an initial invasive strategy (1,505 patients) or an initial conservative strategy (1,472 patients). The primary endpoint for this analysis was the trajectory of angina frequency over a 2-year period, which was assessed using the Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score. Scores were categorised as daily/weekly, monthly, or no angina.
Researchers identified six distinct and qualitatively similar patterns of angina trajectories in both treatment arms:
1. Rapid resolution
2. Gradual resolution
3. Early improvement with persistent infrequent angina
4. Severe angina with improvement
5. Modest angina with minimal change
6. Severe angina without improvement
The distribution of these patterns differed significantly between the two groups. In the invasive strategy group, the most common trajectories were favourable, including 'rapid resolution' (27.1%) and 'early improvement with persistent infrequent angina' (32.1%). In contrast, the conservative strategy group most frequently showed 'modest angina with minimal change' (42.1%), with fewer patients experiencing 'rapid resolution' (12.8%) or 'early improvement with persistent infrequent angina' (10.2%).
According to the ISCHEMIA Research Group, these findings demonstrate that “patients with chronic coronary disease and angina experienced diverse symptom trajectories, ranging from rapid resolution to severe or persistent angina.”¹ They noted that a greater proportion of patients managed conservatively experienced unfavourable angina patterns over the 2-year follow-up compared to those treated invasively.
Monitoring these individual symptom trajectories over time could be a valuable clinical tool. It may help to identify patients with persistent or severe symptoms who are not responding to initial therapy and could benefit from additional or alternative treatments to improve their health status and quality of life.
This study was funded by the National Heart, Lung, and Blood Institute (NHLBI).
References
1. Ikemura N, Jones PG, Fu Z, et al. Trajectories of Angina After Initial Invasive vs Conservative Strategy for Chronic Coronary Disease. JACC. 2025;86(11):782-793. https://doi.org/10.1016/j.jacc.2025.06.044
2. Spertus JA, Jones PG, Maron DJ, et al. Health-status outcomes with invasive or conservative care in coronary disease. N Engl J Med. 2020;382:1408-1419. https://doi.org/10.1056/NEJMoa1916370
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