Discussion
chest tightness, angina, physician-adjudicated angina, dyspnea, chest pain, post-PCI angina, atrial fibrillation, heart failure
MYOCARDIAL INFARCTION, ANGINAL ATTACKS, ATRIAL FIBRILLATION, HEART FAILURE, HYPERTENSION
One in 3 patients in the TARGET-FFR randomized trial reported angina 3 months after undergoing PCI which, while a substantial proportion, is not unprecedented. In the ABSORB IV trial, 39% (494/1265) of patients in the drug-eluting stent arm had physician-adjudicated angina or angina-equivalent symptoms at 1-year follow-up.As the impact of anginal symptoms is inherently subjective, we concluded that attempting to define a level of post-PCI angina that might be acceptable to patients or represent a clinically meaningful improvement would be arbitrary and ultimately futile. Improved but persistent symptoms may be considered a success by some patients yet be completely unacceptable to others, so we therefore, determined a complete absence of patient-reported angina after PCI to represent the gold standard. The SAQ-AF domain asks patients to report the frequency of “chest pain, chest tightness, or anginal attacks” over the preceding 4 weeks with a score <100 indicating at least one anginal episode within that period. Accordingly, we adopted a follow-up SAQ-AF score of <100 as the definition of post-PCI.Approximately 6% of participants reporting angina after stenting did not have symptoms prior to their intervention which highlights the importance of ascertaining the indication for and appropriateness of PCI with patients prior to embarking upon the procedure, particularly for those who are asymptomatic.Patients reporting post-PCI angina had a higher burden of cardiovascular risk factors, including cigarette smoking, prior myocardial infarction, and atrial fibrillation at baseline. The higher rates of oral anticoagulants and concomitant lower rate of antiplatelets prescribed at baseline among patients reporting post-PCI angina are likely just commensurate with the higher incidence of atrial fibrillation in this group. As there was no difference in the incidence of the heart failure or hypertension, the higher rate of diuretic therapy may relate to prescriptions for dyspnea thought to represent an angina-equivalent symptom.Patients with post-PCI angina had more severe symptoms at baseline (higher incidence of both CCS class 2 and 3 angina and self-reported rates of daily and weekly angina) and were prescribed more antianginal agents with greater use of oral and sublingual nitrates than those who were angina-free postprocedure. Patients experiencing any angina post-PCI reported effectively no improvement in quality of life as assessed by the mean change in their EQ-5D-5L weighted health index score (