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In the COURAGE trial, percutaneous coronary intervention (PCI), added to optimal medical therapy, did not reduce the subsequent rate of death or myocardial infarction among patients with chronic coronary disease. A quality-of-life analysis showed that measures of health status improved significantly with either strategy, but patients in the PCI group had greater initial improvements. In the COURAGE trial, percutaneous coronary intervention (PCI), added to optimal medical therapy, did not reduce the subsequent rate of death or myocardial infarction among patients with chronic coronary disease. A quality-of-life analysis showed that measures of health status improved significantly with either strategy, but patients in the PCI group had greater initial improvements. Clinical trials involving patients with chronic coronary artery disease, in contrast to those involving patients with acute coronary syndromes, have not shown that percutaneous coronary intervention (PCI) prevents major cardiovascular events. 1 – 5 The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial compared a strategy of PCI plus optimal medical therapy with optimal medical therapy alone and showed no significant difference in the rate of the primary end point (death or myocardial infarction) during a median follow-up period of 4.6 years. 6 Among patients with stable coronary artery disease, PCI is indicated for the relief of angina. 2 , 3 , 7 , . . .

BackgroundIn patients with suspected angina pectoris, CT coronary angiography (CTCA) clarifies the diagnosis, directs appropriate investigations and therapies, and reduces clinical events. The effect on patient symptoms is currently unknown.MethodsIn a prospective open-label parallel group multicentre randomised controlled trial, 4146 patients with suspected angina due to coronary heart disease were randomised 1:1 to receive standard care or standard care plus CTCA. Symptoms and quality of life were assessed over 6 months using the Seattle Angina Questionnaire and Short Form 12.ResultsBaseline scores indicated mild physical limitation (74±0.4), moderate angina stability (44±0.4), modest angina frequency (68±0.4), excellent treatment satisfaction (92±0.2) and moderate impairment of quality of life (55±0.3). Compared with standard care alone, CTCA was associated with less marked improvements in physical limitation (difference −1.74 (95% CIs, −3.34 to −0.14), p=0.0329), angina frequency (difference −1.55 (−2.85 to −0.25), p=0.0198) and quality of life (difference −3.48 (−4.95 to −2.01), p<0.0001) at 6 months. For patients undergoing CTCA, improvements in symptoms were greatest in those diagnosed with normal coronary arteries or who had their preventative therapy discontinued, and least in those with moderate non-obstructive disease or had a new prescription of preventative therapy (p<0.001 for all).ConclusionsWhile improving diagnosis, treatment and outcome, CTCA is associated with a small attenuation of the improvements in symptoms and quality of life due to the detection of moderate non-obstructive coronary artery disease.Trial registration number:NCT01149590.

Greater optimism regarding recovery from chronic illness is associated with improved quality of life and clinical outcomes. We performed a post-hoc analysis on the association between optimism and outcomes in Ranolazine in Patients with Incomplete Revascularization after Percutaneous Coronary Intervention (RIVER-PCI), a randomized trial in patients with chronic angina pectoris who had incomplete revascularization following percutaneous coronary intervention. At baseline, patients answered how much they agreed with the phrase, “I am optimistic about my future and returning to a normal lifestyle.” We evaluated the association between baseline optimism and time to ischemia-driven hospitalization or revascularization using a Cox model, and the association between baseline optimism and change in frequency of angina pectoris using a mixed measures model. Of 2,389 patients, 782 (33.2%) were very optimistic (“strongly agree”), 1,000 (42.4%) were optimistic (“agree”), 451 (19.1%) were neutral (“undecided”), and 123 (5.2%) were not optimistic (“disagree” or “strongly disagree”). Very optimistic patients had a lower prevalence of co-morbidities and less severe angina at baseline than less optimistic patients. The rate of ischemia-driven revascularization or hospitalization was higher in neutral and not optimistic patients compared with very optimistic patients; this finding persisted after adjustment for co-morbidities and baseline angina frequency (hazard ratio 1.42, 95% confidence interval 1.14 to 1.77 for neutral vs very optimistic; hazard ratio 1.38, 95% confidence interval 0.98 to 1.94 for not optimistic vs very optimistic). Neutral and not optimistic patients also had less improvement in angina than very optimistic patients. In conclusion, in patients with angina, those with more self-reported optimism had better health status outcomes. Whether structured interventions targeting optimism improve outcomes in these patients warrants further study.

Abstract ObjectiveTo evaluate the effect of opt-in compared with opt-out recruitment strategies on response rate and selection bias. DesignDouble blind randomised controlled trial. SettingTwo general practices in England. Participants510 patients with angina. InterventionPatients were randomly allocated to an opt-in (asked to actively signal willingness to participate in research) or opt-out (contacted repeatedly unless they signalled unwillingness to participate) approach for recruitment to an observational prognostic study of patients with angina. Main outcome measuresRecruitment rate and clinical characteristics of patients. Results The recruitment rate, defined by clinic attendance, was 38% (96/252) in the opt-in arm and 50% (128/258) in the opt-out arm (P = 0.014). Once an appointment had been made, non-attendance at the clinic was similar (20% opt-in arm v 17% opt-out arm; P = 0.86). Patients in the opt-in arm had fewer risk factors (44% v 60%; P = 0.053), less treatment for angina (69% v 82%; P = 0.010), and less functional impairment (9% v 20%; P = 0.023) than patients in the opt-out arm. Conclusions The opt-in approach to participant recruitment, increasingly required by ethics committees, resulted in lower response rates and a biased sample. We propose that the opt-out approach should be the default recruitment strategy for studies with low risk to participants.

Objectives: Refractory angina patients suffer debilitating chest pain despite optimal medical therapy and previous cardiovascular intervention. Cardiac rehabilitation is often not prescribed due to a lack of evidence regarding potential efficacy and patient suitability. A randomised controlled study was undertaken to explore the impact of cardiac rehabilitation on cardiovascular risk factors, physical ability, quality of life and psychological morbidity among refractory angina sufferers. Methods: Forty-two refractory angina patients (65.1 ± 7.3 years) were randomly assigned to an 8-week Phase III cardiac rehabilitation program or symptom diary control. Physical assessment, Progressive Shuttle Walk test, Hospital Anxiety and Depression Scale, Health Anxiety Questionnaire, the York Angina Beliefs scale, ENRICHD Social Support Instrument and SF-36 were completed before and after intervention and at 8-week follow-up. Results: Following cardiac rehabilitation, patients demonstrated improved physical ability compared with controls in Progressive Shuttle Walk level attainment (p = 0.005) and total distance covered (p = 0.015). Angina frequency and severity remained unchanged in both groups, with the control demonstrating worsening SF-36 pain scale (63.43 ± 22.28 vs. 55.46 ± 23.98, p = 0.025). Cardiac rehabilitation participants showed improved Health Anxiety Questionnaire reassurance (1.71 ± 1.72 vs. 1.14 ± 1.23, p = 0.026) and York Beliefs anginal threat perception (12.42 ± 4.58 vs. 14.35 ± 4.73, p = 0.05) after cardiac rehabilitation. Physical measures were broadly unaffected. Conclusions: Cardiac rehabilitation can be prescribed to improve physical ability without affecting angina frequency or severity among patients with refractory angina.

Background Most people referred to rapid access chest pain clinics have non-cardiac chest pain, and in those diagnosed with stable coronary heart disease, guidance recommends that first-line treatment is usually medication rather than revascularisation. Consequently, many patients are not reassured they have the correct diagnosis or treatment. A previous trial reported that, in people with non-cardiac chest pain, a brief discussion with a health psychologist before the tests about the meaning of potential results led to people being significantly more reassured. The aim of this pilot was to test study procedures and inform sample size for a future multi-centre trial and to gain initial estimates of effectiveness of the discussion intervention. Methods This was a two-arm pilot randomised controlled trial in outpatient rapid access chest pain clinic in 120 people undergoing investigation for new onset, non-urgent chest pain. Eligible participants were randomised to receive either: a discussion about the meaning and implication of test results, delivered by a nurse before tests in clinic, plus a pre-test pamphlet covering the same information (Discussion arm) or the pre-test pamphlet alone (Pamphlet arm). Main outcome measures were recruitment rate and feasibility for a future multi-centre trial, with an estimate of reassurance in the groups at month 1 and 6 using a 5-item patient-reported scale. Results Two hundred and seventy people attended rapid access chest pain clinic during recruitment and 120/270 participants (44%) were randomised, 60 to each arm. There was no evidence of a difference between the Discussion and Pamphlet arms in the mean reassurance score at month 1 (34.2 vs 33.7) or at month 6 (35.3 vs 35.9). Patient-reported chest pain and use of heart medications were also similar between the two arms. Conclusions A larger trial of the discussion intervention in the UK would not be warranted. Patients reported high levels of reassurance which were similar in patients receiving the discussion with a nurse and in those receiving a pamphlet alone. Trial registration Current Controlled Trials ISRCTN60618114 (assigned 27.05.2011).

Angina is a common symptom in patients with coronary artery disease (CAD); however, its impact on patients’ quality of life over time is not well understood. We sought to determine the longitudinal association of angina frequency with quality of life and functional status over a 5-year period. We used data from the Heart and Soul Study, a prospective cohort study of 1,023 outpatients with stable CAD. Participants completed the Seattle Angina Questionnaire (SAQ) at baseline and annually for 5 years. We evaluated the population effect of angina frequency on disease-specific quality of life (SAQ Disease Perception), physical function (SAQ Physical Limitation), perceived overall health, and overall quality of life, with adjusted models. We evaluated these associations within the same year and with a time-lagged association between angina and quality of life reported 1 year later. Generalized estimating equation models were used to account for repeated measures and within-subject correlation of responses. Over 5 years of follow-up, patients with daily or weekly angina symptoms had lower quality of life scores (52 vs 89, p <0.001) and greater physical limitation (61 vs 86, p <0.001) after adjustment. Compared with patients with daily or weekly angina symptoms, those with no angina symptoms had 2-fold greater odds of better quality of life (odds ratio 2.39, 95% confidence interval 1.76 to 3.25) and 5-fold greater odds of better perceived overall health (odds ratio 5.45, 95% confidence interval 3.85 to 7.73). In conclusion, angina frequency is strongly associated with quality of life and physical function in patients with CAD. Even after modeling to adjust for both clinical risk factors and repeated measures within subjects, we found that less frequent angina symptoms were associated with better quality of life.

Patients with angina and unobstructed coronary arteries (ANOCA) are frequently encountered in clinical practice. These cases represent a diagnostic and therapeutic challenge and are often characterized by a long patient journey until a diagnosis of coronary vasomotor disorders is established. Moreover, the unsatisfactory management of such patients leads to insecurity, ongoing symptoms, and psychological sequelae such as anxiety or depression. Currently, the psychological burden in patients with ANOCA is underestimated, underexplored, and undertreated. This review gives a new perspective on the pathophysiology of coronary vasomotor disorders including psychological risk factors and calls for comprehensive care by interdisciplinary ANOCA clinics.

Background: Patient-reported outcomes are integral to chronic coronary syndrome (CCS) care. The Seattle Angina Questionnaire (SAQ) is validated and prognostic, yet its clinical integration in Bulgaria is undefined. Aim: The aim of this study was to provide a structured, clinically oriented framework for integrating the SAQ into the full CCS care pathway—from screening and phenotyping (obstructive vs. ANOCA/INOCA endotypes) to diagnostics, mechanism-tailored therapy, and follow-up—while outlining a pragmatic roadmap for Bulgarian implementation. Methods: We conducted a semi-structured narrative review (1995–2024) of SAQ’s validation, prognostic utility, and implementation in the literature, augmented with guideline-based frameworks for CCS/ANOCA care. Results: The SAQ (and SAQ-7) shows strong reliability and responsiveness and independently predicts health status and clinical outcomes. Embedding the SAQ at baseline, at 4–12 weeks after therapy changes, and after 6–12 months enables symptom-guided decision-making. A phenotype-guided pathway is proposed that couples the SAQ with CAD burden assessment and—where indicated—ANOCA diagnostics (CFR/IMR, vasoreactivity testing). Mechanism-tailored therapy maps to endotypes (e.g., VSA → CCB ± nitrates; MVA → beta-blocker/ACEi/statin ± ranolazine; obstructive CADGDMT ± PCI/CABG). A minimum dataset, metrics, and registry fields are specified for Bulgarian deployment. Conclusions: A clinically structured framework clarifies how the SAQ adds value beyond description—by informing triage, treatment selection, and follow-up across CCS phenotypes. This approach provides educational guidance and a practical blueprint for pilot implementation in Bulgaria.

A randomized, controlled trial was conducted in an outpatient setting to examine the effect of beta-blocker dosing frequency on patient compliance, clinical outcome, and health-related quality of life in patients with stable angina pectoris. One hundred and twelve beta-blockers-naive outpatients with stable angina pectoris were randomized to receive betaxolol, 20 mg once daily or metoprolol tartrate, 50 mg twice daily for 8 weeks. The principal outcome measure was overall compliance measured electronically, whereas secondary outcome measures were drug effectiveness and health-related quality of life. The overall compliance was 86.5 +/- 21.3% in the betaxolol group versus 76.1 +/- 26.3% in the metoprolol group (p < 0.01), and the correct number of doses was taken on 84.4 +/- 21.6% and 64.0 +/- 31.7% of treatment days, respectively (p < 0.0001). The percentage of missed doses was 14.5 +/- 21.5% in the once-daily group and 24.8 +/- 26.4% in the twice-daily group (p < 0.01). The percentage of doses taken in the correct time window (58.6% vs 42.0%, p = 0.01), correct interdose intervals (77.4% v 53.1%, p < 0.0001), and therapeutic coverage (85.6% vs 73.7%, p < 0.001) were significantly higher in the once-daily group. Both studied drugs had similar antianginal effectiveness. Health-related quality of life improved in both groups, but this increase was more pronounced in the betaxolol arm in some dimensions. The study demonstrates that patient compliance with once-daily betaxolol is significantly better than with twice daily metoprolol. Similarly, this treatment provides better quality of life. These results demonstrate possible therapeutic advantages of once-daily over twice-daily beta-blockers in the treatment of stable angina pectoris.