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Long-Term Benefits and Limitations of Combined Antianginal Drug Therapy in Elderly Patients with Symptomatic Chronic Coronary Artery Disease

Division of Cardiology, University Hospital, Basel, Switzerland

Christoph Kaiser, MD

Division of Cardiology, University Hospital, Basel, Switzerland

Michael J. Zellweger, MD

Division of Cardiology, University Hospital, Basel, Switzerland

Leticia Grize, PhD

Institute for Social and Preventive Medicine, University Hospital, Basel, Switzerland

Paul Erne, MD

Division of Cardiology, Kantonsspital, Luzern, Switzerland

Ronald A. Schoenenberger, MD

Department of Internal Medicine, Buergerspital, Solothurn, Switzerland

Matthias E. Pfisterer, MD

Division of Cardiology, University Hospital, Basel, Switzerland

TIME Investigators

Background: Chronic angina is a common and disabling disorder in the elderly. Combined antianginal drug treatment represents the mainstay of therapy in this population. However, there is a paucity of data regarding the effect of this strategy on long-term outcome in the elderly.

Methods: To assess the long-term effect of combined antianginal drug therapy in elderly individuals, we performed a long-term follow-up analysis of all 148 patients of the Trial of Invasive versus Medical therapy in Elderly (TIME) patients with chronic symptomatic coronary-artery disease assigned to an optimized medical therapy strategy. Angina severity, measures of quality of life (QOL), and survival were assessed after a median of 3.7 (0.1-6.9) years.

Results: At baseline, patients were 79.8 ± 3.5 years old with Canadian Cardiovascular Society (CCS) class angina 3.0 ± 0.7 despite the use of 2.4 ± 0.6 antianginal drugs. Although antianginal drugs were increased to 2.8 ± 0.9 (P < .01), 63 (43%) patients needed revascularization for refractory symptoms during the first year of observation (REVASC). At baseline, REVASC patients had more frequently CCS class 4 angina (37% vs 20%, P < 0.05) but reported less prior heart failure (5% vs 20%, P < 0.01), fewer prior cerebral events (3% vs 13%, P < .05) and a lower rate of two or more comorbidities (10% vs 33%, P < .01) than patients on continued drug therapy (DRUG). At long-term follow-up, angina severity was still higher in DRUG compared to REVASC patients (CCS class, 1.8 ± 1.6 vs 1.0 ± 1.4, P < .05) despite more antianginal drugs (2.1 ± 1.1 vs 1.5 ± 1.0, P < .01), whereas measures of QOL had improved similarly in both groups. In addition, long-term mortality was significantly higher in DRUG than in REVASC patients (38% vs 13%, P < .01).

Conclusion: Combined antianginal drug therapy successfully relieved symptoms in most elderly patients with chronic angina but failed to do so in 43%. Patients who needed revascularization for refractory symptoms reported less angina, despite lower drug use during long-term follow-up and had a better long-term survival. Thus, the widely used strategy to increase antianginal drug therapy in elderly patients instead of evaluating them for revascularization should be reconsidered.

Key Words: chronic angina • elderly • antianginal therapy

Journal of Cardiovascular Pharmacology and Therapeutics, Vol. 10, No. 1, 29-37 (2005)
DOI: 10.1177/107424840501000104


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