Background. After PCI for MI, angina has important implications on quality of life and healthcare utilization

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1 Angina Prevalence and Management for Myocardial Infarction Patients Treated with Percutaneous Coronary Intervention: Insights from the TRANSLATE-ACS Study Alexander C. Fanaroff, Lisa A. Kaltenbach, Eric D. Peterson, Connie N. Hess, David J. Cohen, Gregg C. Fonarow, Tracy Y. Wang on behalf of the TRANSLATE-ACS Investigators

2 Background After PCI for MI, angina has important implications on quality of life and healthcare utilization 1.5-fold increased risk of re-admission and repeat revascularization compared with patients without angina 2-fold increased risk of developing new depressive symptoms Lower self-perceived health and physical function Hess CN et al. Circulation. 2017;135: Maddox TM et al. Archives of Internal Medicine. 2008;168: Gardner AW et al. Angiology. 2011: Doll JA et al. Journal of the American Heart Association. 2016;5:e003205

3 Guideline Recommendations: A Stepped Approach Beta blocker + sublingual nitrate Class I, LOE B Calcium channel blocker or long-acting nitrate Class I, LOE B Ranolazine Class IIa, LOE A Revascularization Class I, LOE B Fihn et al ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. Journal of the American College of Cardiology. 2012;60:e44-e164.

4 Objectives Describe longitudinal patterns of patientreported angina after PCI for MI Describe patterns of anti-angina medication usage among patients with self-reported angina after PCI for MI

5 Study design A contemporary, longitudinal observational study of patients with acute MI treated with PCI and P2Y 12 inhibitor therapy at > 200 hospitals from 2010 to 2012 Telephone interviews at 6 weeks, 6 months, and 12 months collected medications and Seattle Angina Questionnaire angina frequency SAQ angina frequency questions asks about frequency of angina symptoms and sublingual nitroglycerin use Responses summed to derive SAQ angina frequency score 100 = no angina; = monthly angina; = weekly angina; 0-39 = daily angina Spertus JA et al. Journal of the American College of Cardiology. 1995;25:

6 Patient population 12,365 patients enrolled in TRANSLATE-ACS 10,870 patients with evaluation of 6 week angina 3190 patients with stable angina for descriptive analysis of anti-anginal medication usage Died in-hospital (n = 14) Missing angina frequency at 6 weeks (n = 1,481) No angina at 6 weeks (n = 7,680)

7 Methods Report proportion of patients with 6-week angina with continued angina at 6 months and 12 months Report proportion of patients with angina taking nonbeta blocker (NBB) anti-anginal medications at 6 weeks, 6 months, and 12 months By angina frequency (monthly, daily/weekly) Among patients with persistent angina throughout follow-up Report proportion of patients with angina taking NBB anti-anginal medications at the time of repeat PCI

8 Baseline characteristics Demographics and Medical History Age (median) 57 Female sex 31.9% Black/African American 11.2% No insurance 18.0% Diabetes 26.0% Multivessel CAD 48.8% Cerebrovascular disease 7.7% Peripheral vascular disease 6.4% Details of Index MI and PCI STEMI 57.1% Multi-vessel disease 48.8% Discharge medications P2Y 12 inhibitor 99.5% Statin 95.3% Aspirin 98.7% ACEI/ARB 73.5% Beta blocker 93.6%

9 Proportion of patients Angina prevalence after PCI for MI 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 3% 18% 40% 79% 33% 6 weeks 6 months 12 months Time from index MI Monthly Weekly Daily

10 Percentage of patients Beta blocker usage 100% 90% 80% 90% 86% 82% 70% 60% 50% 40% 30% 20% 10% 0% 6 weeks 6 months 12 months

11 % of patients taking NBB antiangial medications NBB anti-angina medication usage CCB+Nitrate+Ran 30 Nitrate+Ran % 22% 23% CCB+Ran CCB+Nitrate 15 Ranolazine alone weeks 6 months 12 months Long-acting nitrate alone Calcium channel blocker alone

12 % with angina taking NBB anti-anginal NBB anti-anginal medication usage by angina severity % 16% 34% 18% 38% 22% Number of non-beta blocker antianginals Three Two One Daily/weekly Monthly Daily/weekly Monthly Daily/weekly Monthly 6 weeks 6 months 12 months Angina Frequency by time elapsed from MI

13 Persistent angina 1056 (33%) of 3190 patients with 6-week angina had angina for the entirety of 12 months follow-up 727 of 1056 (69%) never took a NBB antiangina medication 61% of patients with daily/weekly angina at 12 months

14 Anti-anginal medication usage and repeat PCI 381 of 3190 patients with 6 week angina had repeat PCI after 6 weeks through the end of follow-up 99 (26%) of 381 were prescribed a NBB antiangina medication at the time of PCI 19% taking 1 NBB medication 6% taking 2 NBB medications 1% taking 3 NBB medications

15 Limitations Analysis limited to patient-reported angina; unclear whether these patients have objective myocardial ischemia that would benefit from anti-angina medications Did not capture exercise frequency or tolerance, and it is possible that patients reporting angina are actually more active than those that did not Do not report on outcomes related to anti-angina medication usage; any outcomes analysis would be limited by confounding by indication

16 Conclusions Angina is present at 6 weeks in ~ 40% of patients undergoing PCI for MI and a substantial proportion continue to have angina at 12 months Non-beta blocker anti-angina medications are used infrequently in this patient population, even among those with more severe/persistent angina, and those undergoing PCI for continued angina symptoms Strategies to improve clinician recognition and treatment of angina symptoms are needed

17 Thank you