Angina or intermittent claudication: which is worse?

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1 Angina or intermittent claudication: which is worse? A comparison of self-assessed general health, mental health, quality of life and mortality in 7,403 participants in the 2003 Scottish Health Survey. Dr Sally C Inglis RN, PhD, NFESC University of Glasgow, Glasgow, United Kingdom Baker IDI Heart and Diabetes Institute, Melbourne, Australia Dr Jim Lewsey, Dr Kate MacIntyre, Professor John McMurray No conflicts of interest to report.

2 Purpose To compare the impact of intermittent claudication, a common symptom of lower limb peripheral artery disease and angina, a common symptom of coronary artery disease on self-assessed general health, mental health, health-related quality of life and prognosis. We were interested in identifying which symptom led to worse outcomes for the participants of the 2003 Scottish Health Survey 1,2, a population-based epidemiological survey. 1. Zaninotto P, et al. In Bromley C, Sproston K, Shelton N, eds. Edinburgh: Blackwell, Gray L, et al.int J Epidemiol 2010;39:

3 Angina and Intermittent Claudication Intermittent claudication and angina are common symptoms of atherosclerotic arterial disease. Each causes significant reduction in health-related quality of life and considerable impairment of function and mobility 1-5. The impact which these isolated symptoms have on communitybased individuals 5 is rarely documented, or compared with each other 2,5 for members of the same population. 1. Broddadottir H, et al.eur J of Cardiovas Nurs 2009;8: de Graaf JC, et al. Ann Vasc Surg 2002;16: Issa SM, et al. Vasc Med 2010;15: Pell JP. Eur J Vasc Endovasc Surg 1995;9: Dumville JC, et al. Br J Gen Pract 2004;54:

4 Previous research De Graaf et al (2002) 1 89 patients (mean age 72 ±13; 61% male) with severe peripheral artery disease (PAD) with critical limb ischaemia (Fontaine stage II or III) 89 patients (mean age 60±11; 71% male) with coronary artery disease (CAD) (CCS Class I-III, Braunwald class I) Overlap between symptom groups Patients with PAD had lower scores than CAD patients on SF-36 Dumville et al (2004) 2 Edinburgh Artery Study 31 participants with intermittent claudication only 99 participants with angina only No significant difference on physical or mental component scores of SF-36 between the two groups. 1. de Graaf JC, et al. Ann Vasc Surg 2002;16: Dumville JC, et al. Br J Gen Pract 2004;54:

5 Methods: 2003 Scottish Health Survey 1,2 Cross-sectional, random sample of 8,148 adults aged 16+ years living in Scotland. Survey focused on cardiovascular disease and risk factors. For consenting participants (n=7,425, 91% survey cohort), the survey has been linked to hospitalisation and mortality records, allowing follow-up to 31 December % female; 16 to 95 years of age. 1.Zaninotto P, et al. In Bromley C, Sproston K, Shelton N, eds. Edinburgh: Blackwell, Gray L, et al.int J Epidemiol 2010;39:

6 Methods: Symptom Questionnaires Rose Angina Questionnaire (RAQ) 1 Grade 1: chest pain or discomfort when walking uphill or hurrying Grade 2: chest pain or discomfort when walking at an ordinary pace on the level Edinburgh Claudication Questionnaire (ECQ) 2 Grade 1: leg pain or discomfort when walking uphill or hurrying Grade 2: leg pain or discomfort when walking at an ordinary pace on the level 1. Rose GA, et al. Cardiovascular survey methods Geneva, World Health Organization. 2. Leng GC, Fowkes FGR. J Clin Epidemiol 1992;45:

7 Methods: Questionnaires, measurements and outcomes Self-assessment of general health (SAGH) [100%] very bad, bad, fair, good, very good General Health Questionnaire (GHQ) 3 [96%] Score of 4 identified a potential mental health problem Short-Form 12 (SF-12) 4 [85%] Mean physical component score (PCS) Mean mental component score (MCS) All-cause mortality at 5 years 1. Rose GA, et al. Cardiovascular survey methods Geneva, World Health Organization. 2. Leng GC, Fowkes FGR. J Clin Epidemiol 1992;45: Goldberg DP. User's Guide to the General Health Questionnaire. NFER-Nelson, Ware JE et al. SF-12: how to score the SF-12 physical and mental health summary scales. Lincoln: Quality Metric, 2001.

8 Methods: Statistical analysis Survey and mortality data were compared for adult participants with either angina or intermittent claudication (or neither symptom). Proportions were compared using chi-square. Means were compared using two sample t-test. All-cause mortality was examined using Kaplan-Meier analysis and compared using a log-rank test. Multi-variable linear regression modelling was performed to examine the relationship between demographic variables and intermittent claudication and angina on the mental and physical component scores of the SF-12.

9 Symptom prevalence Screening for intermittent claudication and angina indicated that of 7,425 individuals: 2.3% had intermittent claudication 2.8% had angina 0.3% had both symptoms and were excluded

10 Angina n=205 Int. claudication n=173 P-value Age, mean (SD) 60.0 (14.6) 60.5 (15.4) 0.8 Male sex, % 45.4% 40.5% 0.3 Socioeconomic deprivation Martial status Age completed fulltime education 0.04 Not yet finished/never went 4.4% 5.8% <14 16 years 85.4% 76.2% 17 or 18 years 6.8% 6.9% 19 years 3.4% 11.0% Hypertension 57.4% 46.2% 0.03 Myocardial infarction 21.1% 9.3% Respiratory condition 25.9% 12.7% Stroke 6.9% 7.5% 0.8 Diabetes 17.1% 15.0% 0.6 Current smoker 33.7% 36.4% 0.6 Ever smoked 76.6% 77.5% 0.8 * Proportions calculated using denominator for available data.

11 Angina vs. Intermittent Claudication: Self-assessed general health Participants with angina rated their health worse than participants with intermittent claudication (p<0.001). Good or very good: 46% intermittent claudication vs. 25% angina Bad or very bad: 13% intermittent claudication vs. 32% angina When assessed according to symptom severity: Grade 1 angina vs. Grade 1 intermittent claudication: p=0.003 Grade 2 angina vs. Grade 2 intermittent claudication: p<0.001 Grade 2 angina vs. Grade 1 intermittent claudication: p<0.001 Grade 1 angina vs. Grade 2 intermittent claudication: p=0.5

12 Angina vs. Intermittent Claudication: Mental Health (GHQ score 4) Participants with angina were more likely to have a mental health problem relative to those with intermittent claudication: 34% angina vs. 21% intermittent claudication (p=0.001) When assessed according to symptom severity Grade 1 angina 31% vs. Grade 1 intermittent claudication 20% (p=0.008) Grade 2 angina 40% vs. Grade 2 intermittent claudication 22% (p<0.001) Grade 2 angina 40% vs. Grade 1 intermittent claudication 20% (p=0.001) Grade 1 angina 31% vs. Grade 2 intermittent claudication 22% (p=0.3)

13 Angina vs. Intermittent Claudication: Quality of life (SF-12) Physical component score Participants with angina had lower mean PCS on the SF-12 compared to participants with intermittent claudication: Angina, 35 (±12) vs. Intermittent Claudication, 42 (±11) (p<0.001) When assessed according to symptom severity Grade 1 angina, 38 vs. Grade 1 intermittent claudication, 44 (p<0.001) Grade 2 angina, 29 vs. Grade 2 intermittent claudication, 39 (p<0.001) Grade 2 angina, 29 vs. Grade 1 intermittent claudication, 44 (p<0.001) Grade 1 angina, 38 vs. Grade 2 intermittent claudication, 39 (p=0.2)

14 Angina vs. Intermittent Claudication Quality of life (SF-12) Mental component score Participants with angina had lower mean MCS on the SF-12 compared to participants with intermittent claudication Angina, 47 (±12) vs. Intermittent Claudication, 52 (±9) (p<0.001) When assessed according to symptom severity Grade 1 angina, 47 vs. Grade 1 intermittent claudication, 52 (p=0.002) Grade 2 angina, 46 vs. Grade 2 intermittent claudication, 53 (p<0.001) Grade 2 angina, 46 vs. Grade 1 intermittent claudication, 52 (p<0.001) Grade 1 angina, 47 vs. Grade 2 intermittent claudication, 53 (p<0.001)

15 Multivariable linear regression of SF-12 scores Physical score R 2 = 0.28 Mental score R 2 = 0.10 β P-value β P-value Angina < <0.001 Intermittent claudication Female <0.001 Socioeconomic deprivation II III < IV < V < Marital status Married Separated Divorced Widowed Not a current smoker <0.001

16 Multivariable linear regression of SF-12 scores Physical score R 2 = 0.28 Mental score R 2 = 0.10 β P-value β P-value Age finished FT education Never went to school or under or over Comorbidities Hypertension < <0.001 Myocardial infarction < Stroke < <0.001 Diabetes < Respiratory condition < <0.001 Age (per additional year) < <0.001

17 Angina vs. Intermittent Claudication: Quality of life (SF-12) Physical component score In a multivariable analysis, having angina (β -6.63) or intermittent claudication (β -2.44) significantly decreased the PCS. 28% of the variation in PCS was accounted for in the model. Variables which significantly predicted a lower PCS included: older age (per year) (β -0.17), greater socio-economic deprivation (β -2.99), history of hypertension (β -2.81), MI (β -6.36), stroke (β -7.37), diabetes (β -3.79) or respiratory condition (β -6.66). Variables which significantly predicted a higher PCS included: being married (β 1.39), separated (β 2.19) or widowed (β 2.24), not smoking (β 1.07) and completing fulltime education when aged 16 (β 1.66), 18 (β 1.99) or 19 years or older (β 2.67).

18 Angina vs. Intermittent Claudication: Quality of life (SF-12) Mental component score In a multivariable analysis, angina (β -4.25) was a significant predictor of a decrease in the MCS. 10% of the variation in MCS was accounted for in the model. Demographic variables which significantly predicted a lower MCS included: female sex (β 1.19), greatest socio-economic deprivation (β 1.71), history of hypertension (β -1.75), stroke (β -3.99) or respiratory condition (β -2.35), being separated (β -2.63) or divorced (β -1.35), never going to school (β -4.56) or finishing school aged 14 years (β -1.84). Older age (each increasing year) (β 0.10) and not being a current smoker (β 1.83) were the only variables in the model to predict a higher MCS.

19 All-cause mortality at 5 years Angina Intermittent claudication Years All-cause mortality at 5 years was not significantly different between participants with angina or intermittent intermittent claudication claudication (p=0.3): angina Angina: 14.7% [95% CI ] Intermittent claudication: 11.3% [95% CI ]

20 All-cause mortality at 5 years by symptom grade Grade 2 Angina Grade 1 Angina Grade 1 & 2 Intermittent Claudication Years When assessed according to symptom severity Grade 1 angina vs. Grade 1 intermittent claudication (p=0.9) Grade 1 intermittent claudication, no angina Grade 2 angina vs. Grade 2 intermittent claudication (p=0.09) Grade 2 intermittent claudication, no angina Grade 2 angina vs. Grade 1 intermittent claudication (p=0.048) Grade 1 angina, no intermittent claudication Grade 1 angina vs. Grade 2 intermittent claudication (p=1.0) Grade 2 angina, no intermittent claudication

21 Summary of findings Both angina and intermittent claudication were associated with poor self-assessed general health, quality of life, mortality and a high likelihood of mental health problems. Relative to participants with intermittent claudication, individuals with angina fared worse for self-assessed general health, mental health and quality of life. Five year mortality was similar for participants with either symptom. This analysis is unique: these were young (mean age 50 years) predominately female (56%) community-based individuals and we have examined isolated angina and intermittent claudication with a larger number of cases than in previous studies Dumville JC, et al. Br J Gen Pract 2004;54:826-31

22 Limitations There are several limitations to this research: - We have not considered asymptomatic cases; - Questionnaires were used to identify intermittent claudication and angina and these may not be as sensitive or specific as other methods; - We have not taken conditions such as heart failure or cancer into account; - We have not taken treatment or management into account; - We have not considered these outcomes for individuals with both symptoms and there may be additive or synergistic consequences; -Disease-specific quality of life tools 1,2 may be more sensitive. 1. Mehta T, et al. Eur J Vas Endovasc Surg 2003;25: Thompson D, Yu CM. Health Qual Life Outcomes 2003;1:42.

23 Implications of these findings Clinicians are often acutely aware of the implications which angina has quality of life, mobility and function. Intermittent claudication is sometimes not as widely recognised for the same consequences and implications. This research serves to highlight the importance of assessing and intervening to improve quality of life and general health for individuals who suffer from intermittent claudication just as it is for those with angina. Less research has been conducted into nurse-led interventions for individuals with peripheral artery disease or into strategies to improve quality of life for those affected.

24 Conclusion Intermittent claudication and angina are common, debilitating symptoms of atherosclerotic cardiovascular disease. Both impair physical and mental health and impact substantially on health-related quality of life for those affected and their underlying conditions lead to worse prognosis. The impact of angina on these outcomes is greater than that of intermittent claudication, however, the impact of both symptoms on the outcomes assessed should not be ignored.

25 References Broddadottir H, et al. Eur J of Cardiovas Nurs 2009;8: de Graaf JC, et al. Ann Vasc Surg 2002;16: Dumville JC, et al. Br J Gen Pract 2004;54: Goldberg DP. User's Guide to the General Health Questionnaire. NFER-Nelson, Gray L, et al. Int J Epidemiol 2010;39: Issa SM, et al. Vasc Med 2010;15: Leng GC, Fowkes FGR. J Clin Epidemiol 1992;45: Rose GA, et al. Cardiovascular survey methods Geneva, WHO. Pell JP. Eur J Vasc Endovasc Surg 1995;9: Ware JE et al. SF-12: how to score the SF-12 physical and mental health summary scales. Lincoln: Quality Metric, Zaninotto P, et al. In Bromley C, et al. eds. Edinburgh: Blackwell, 2005.

26 Dr Sally Inglis is supported by the Heart Foundation of Australia and the National Health and Medical Research Council of Australia.

27 No Angina or Intermittent Claudication All baseline variables were significantly (p<0.05) different between participants with angina or intermittent claudication for those without either symptom, with exception of % of males. Of participants without intermittent claudication or angina: 74% rated their health as good or very good ; 14.4% may have had a mental health problem; They had the highest mean physical component score on SF-12; They had a significantly higher mental component score than participants with angina, but similar to those with intermittent claudication. 5 year mortality was 5.6%

28 Multivariable linear regression of SF-12 scores Physical score R 2 = 0.27 Mental score R 2 = 0.07 β P-value β P-value Angina < <0.001 Intermittent claudication Female <0.001 Socioeconomic deprivation II III < IV < V < <0.001 Marital status Married 1.39 < Separated <0.001 Divorced <0.001 Widowed

29 Multivariable linear regression of SF-12 scores Physical score R 2 = 0.27 Mental score R 2 = 0.07 β P-value β P-value Age finished FT education 14 or under or over Comorbidities Hypertension < <0.001 Myocardial infarction < Stroke < <0.001 Diabetes < Respiratory condition < <0.001 Age (per additional year) < <0.001

30 Angina vs. Intermittent Claudication: Quality of life (SF-12) Physical component score In a multivariable analysis, having angina or intermittent claudication significantly decreased the PCS 27% of the variation in PCS was accounted for in the model Variables which significantly predicted a lower PCS included: older age, female sex, greater socio-economic deprivation, history of hypertension, MI, stroke, diabetes or respiratory condition Variables which significantly predicted a higher PCS included: being married, separated or widowed and completing fulltime education when aged 19 years

31 Angina vs. Intermittent Claudication: Quality of life (SF-12) Mental component score In a multivariable analysis, angina was a significant predictor of a decrease in the MCS 7% of the variation in MCS was accounted for in the model Demographic variables which significantly predicted a lower MCS included: female sex, greater socio-economic deprivation, history of hypertension, MI, stroke, diabetes or respiratory condition, being separated or divorced, finishing school at a young age ( 14 years) Older age (each increasing year) was the only variable in the model to predict a higher MCS

32 Self-assessed general health,% Angina n=205 Int. claudication n=173 P-value Very good <0.001 Good Fair Bad Very bad A B C D Grade 1 Grade 2 Grade 1 Grade 2 n=137 n=68 n=99 n=74 Very good A vs. C: Good B vs. D: <0.001 Fair B vs. C: <0.001 Bad A vs. D: 0.51 Very bad

33 General health questionnaire% Angina n=194 Int. claudication n=160 P-value A Grade 1 n=132 B Grade 2 n=62 C Grade 1 n=93 D Grade 2 n=67 A vs. C: B vs. D: B vs. C: A vs. D: 0.34

34 SF-12 mean (SD) component score Angina n=163 Int. claudication n=144 P-value Physical 35.0 (11.7) 42.3 (10.6) <0.001 Mental 46.5 (11.7) 52.3 (8.5) <0.001 A B C D Grade 1 Grade 2 Grade 1 Grade 2 n=115 n=48 n=89 n=55 Physical 37.5 (11.8) 28.9 (9.0) 44.0 (10.0) 39.4 (11.0) A vs. C: <0.001 B vs. D: <0.001 B vs. C: <0.001 A vs. D: 0.16 Mental 46.7 (4.8) 46.1 (11.7) 52.0 (8.3) 52.8 (8.9) A vs. C: B vs. D: <0.001 B vs. C: <0.001 A vs. D: <0.001

35 All-cause mortality at 5 years Angina n=205 Int. claudication n=173 P-value All-cause mortality A B C D Grade 1 Grade 2 Grade 1 Grade 2 n=137 n=68 n=99 n=74 All-cause mortality A vs. C: 0.85 B vs. D: 0.09 B vs. C: A vs. D: 0.99

36 All-cause mortality at 5 years Years intermittent claudication neither angina or intermittent claudication angina

37 Coronary artery disease Cerebrovascular disease Peripheral artery disease

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