One-year health status outcomes of unstable angina versus myocardial infarction: a prospective, observational cohort study of ACS survivors

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Unstable angina (UA) patients have lower mortality and reinfarction risks than ST-elevation (STEMI) or non-ST elevation myocardial infarction (NSTEMI) patients and, accordingly, receive less aggressive treatment. Little is known, however, about the health status outcomes (angina, physical function, and quality of life) of UA versus MI patients among survivors of an ACS hospitalization.

In a cohort of 1,192 consecutively enrolled ACS survivors from two Kansas City hospitals, we evaluated the associations between ACS presentation (UA, NSTEMI, and STEMI) and one-year health status (angina, physical functioning and quality of life), one-year cardiac rehospitalization rates, and two-year mortality outcomes, using multivariable regression modeling.

After multivariable adjustment for demographic, hospital, co-morbidity, baseline health status, and treatment characteristics, UA patients had a greater prevalence of angina at 1 year than STEMI patients (adjusted relative risk [RR] = 1.42; 95% CI [1.06, 1.90]) and similar rates as NSTEMI patients (adjusted RR = 1.1; 95% CI [0.85, 1.42]). In addition, UA patients fared no better than MI patients in Short Form-12 physical component scores (UA vs. STEMI score difference -0.05 points; 95% CI [-2.41, 2.3]; UA vs. NSTEMI score difference -1.91 points; 95% CI [-4.01, 0.18]) or Seattle Angina Questionnaire quality of life scores (UA vs. STEMI score difference -1.39 points; 95% CI [-5.63, 2.85]; UA vs. NSTEMI score difference -0.24 points 95% CI [-4.01, 3.54]). Finally, UA patients had similar rehospitalization rates as MI patients (UA vs. STEMI adjusted hazard ratio [HR] = 1.31; 95% CI [0.86, 1.99]; UA vs. NSTEMI adjusted HR = 1.03; 95% CI [0.73, 1.47]), despite better 2-year survival (UA vs. STEMI adjusted HR = 0.51; 95% confidence interval (CI) [0.28, 0.95]; UA vs. NSTEMI adjusted HR = 0.40; 95% CI [0.24, 0.65]).

Although UA patients have better survival rates, they have similar or worse one-year health status outcomes and cardiac rehospitalization rates as compared with MI patients. Clinicians should be aware of the adverse health status outcome risks for UA patients and consider close monitoring for the opportunity to improve their health status and minimize the need for subsequent rehospitalization.


Acute coronary syndrome (ACS) clinical presentations, including ST-elevation myocardial infarction [STEMI], non-ST-elevation myocardial infarction [NSTEMI], and unstable angina [UA], are associated with different mortality and recurrent myocardial infarction (MI) rates 1-4. Accordingly, optimal ACS management, as outlined in the American College of Cardiology/American Heart Association guidelines, stratifies and treats patients differently according to their presentation so that those with the greatest mortality risk receive the most aggressive therapy 1,5-8. However, mortality and rehospitalization are not the only clinically important outcomes. Patient health status outcomes, including their symptom burden, functional status, and health-related quality of life, are critical outcomes from the patient's perspective 9-12. Accordingly, patient health status has recently been advocated as a marker of healthcare quality 13-15.

Despite its clinical importance, little is known about the association between ACS presentation and health status outcomes, especially among UA patients. Given that many cardiac patients are initially identified during an ACS presentation, characterizing this association from the perspective of this presentation is essential to better prognosticate and treat patients with symptomatic coronary disease. Accordingly, we evaluated one-year health status outcomes in a consecutive cohort of ACS patients as a function of their clinical presentation. Identifying patients at risk for poorer health status could identify the need for improved methods of risk stratification so as to improve care and outcomes in ACS patients./>/>/>


  1. Armstrong PW, Fu Y, Chang WC, Topol EJ, Granger CB, Betriu A, Van de Werf F, Lee KL, Califf RM: Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators. Circulation 1998, 98:1860-8.
  2. Furman MI, Dauerman HL, Goldberg RJ, Yarzebski J, Lessard D, Gore JM: Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective. J Am Coll Cardiol 2001, 37:1571-80.
  3. Berger CJ, Murabito JM, Evans JC, Anderson KM, Levy D: Prognosis after first myocardial infarction. Comparison of Q-wave and non-Q-wave myocardial infarction in the Framingham Heart Study. Jama 1992, 268:1545-51.
  4. Rogers WJ, Canto JG, Lambrew CT, Tiefenbrunn AJ, Kinkaid B, Shoultz DA, Frederick PD, Every N: Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the US from 1990 through 1999: the National Registry of Myocardial Infarction 1, 2 and 3. J Am Coll Cardiol 2000, 36:2056-63.
  5. Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, Goodman SG, Granger CB, Steg PG, Gore JM, Budaj A, Avezum A, Flather MD, Fox KA: A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. Jama 2004, 291:2727-33.
  6. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley D, Braunwald E: The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. Jama 2000, 284:835-42.
  7. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr., Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004, 110:82-292.
  8. Morrow DA, Cannon CP, Rifai N, Frey MJ, Vicari R, Lakkis N, Robertson DH, Hille DA, DeLucca PT, DiBattiste PM, Demopoulos LA, Weintraub WS, Braunwald E: Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial. Jama 2001, 286:2405-12.
  9. Spertus J: Selecting end points in clinical trials: What evidence do we really need to evaluate a new treatment? Am Heart J 2001, 142:745-7.
  10. Tsevat J, Dawson NV, Wu AW, Lynn J, Soukup JR, Cook EF, Vidaillet H, Phillips RS: Health values of hospitalized patients 80 years or older. HELP Investigators. Hospitalized Elderly Longitudinal Project. Jama 1998, 279:371-5.
  11. Rumsfeld JS: Health status and clinical practice: when will they meet? Circulation 2002, 106:5-7.
  12. Beinart SC, Sales AE, Spertus JA, Plomondon ME, Every NR, Rumsfeld JS: Impact of angina burden and other factors on treatment satisfaction after acute coronary syndromes. Am Heart J 2003, 146:646-52.
  13. Spertus JA, Jones P, McDonell M, Fan V, Fihn SD: Health status predicts long-term outcome in outpatients with coronary disease. Circulation 2002, 106:43-9.
  14. Spertus JA, Radford MJ, Every NR, Ellerbeck EF, Peterson ED, Krumholz HM: Challenges and opportunities in quantifying the quality of care for acute myocardial infarction: summary from the Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke. J Am Coll Cardiol 2003, 41:1653-63.
  15. Califf RM, Mark DB, Harrell FE Jr., Hlatky MA, Lee KL, Rosati RA, Pryor DB: Importance of clinical measures of ischemia in the prognosis of patients with documented coronary artery disease. J Am Coll Cardiol 1988, 11:20-6.
  16. Cannon CP, Battler A, Brindis RG, Cox JL, Ellis SG, Every NR, Flaherty JT, Harrington RA, Krumholz HM, Simoons ML, Van De Werf FJ, Weintraub WS, Mitchell KR, Morrisson SL, Brindis RG, Anderson HV, Cannom DS, Chitwood WR, Cigarroa JE, Collins-Nakai RL, Ellis SG, Gibbons RJ, Grover FL, Heidenreich PA, Khandheria BK, Knoebel SB, Krumholz HL, Malenka DJ, Mark DB, Mckay CR, Passamani ER, Radford MJ, Riner RN, Schwartz JB, Shaw RE, Shemin RJ, Van Fossen DB, Verrier ED, Watkins MW, Phoubandith DR, Furnelli T: American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndromes Writing Committee). J Am Coll Cardiol 2001, 38:2114-2130.
  17. Alpert JS, Thygesen K, Antman E, Bassand JP: Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000, 36:959-69.
  18. Braunwald E: Unstable angina. A classification. Circulation 1989, 80:410-4.
  19. Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Fihn SD: Monitoring the quality of life in patients with coronary artery disease. Am J Cardiol 1994, 74:1240-1244.
  20. Kimble LP, Dunbar SB, Weintraub WS, McGuire DB, Fazio S, De AK, Strickland O: The Seattle angina questionnaire: reliability and validity in women with chronic stable angina. Heart Dis 2002, 4:206-11.
  21. Dougherty CM, Dewhurst T, Nichol WP, Spertus J: Comparison of three quality of life instruments in stable angina pectoris: Seattle Angina Questionnaire, Short Form Health Survey (SF-36), and Quality of Life Index-Cardiac Version III. J Clin Epidemiol 1998, 51:569-75.
  22. Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Prodzinski J, McDonell M, Fihn SD: Development and evaluation of the Seattle Angina Questionnaire: A new functional status measure for coronary artery disease. J Am Coll Cardiol 1995, 25:333-341.
  23. Ware JE: How to Score Version 2 of the SF-12 Health Survey. Lincoln, RI, QualityMetric Incorporated; 2002.
  24. Beutler E, Waalen J: The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? Blood 2006, 107:1747-50.
  25. Spertus JA, Dawson J, Masoudi FA, Krumholz HM, Reid KJ, Peterson ED, Rumsfeld JS: Prevalence and predictors of angina pectoris one month after myocardial infarction. Am J Cardiol 2006, 98:282-288.
  26. Zou G: A Modified Poisson Regression Approach to Prospective Studies with Binary Data. Am J Epidemiology 2004, 159:702-706.
  27. Rosenbaum PR: Model-based direct adjustment. J Am Stat Assoc 1987, 82:387-394.
  28. Graff LG, Dallara J, Ross MA, Joseph AJ, Itzcovitz J, Andelman RP, Emerman C, Turbiner S, Espinosa JA, Severance H: Impact on the care of the emergency department chest pain patient from the chest pain evaluation registry (CHEPER) study. Am J Cardiol 1997, 80:563-8.
  29. Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD, Kopecky SL, Allen M, Allison TG, Gibbons RJ, Gabriel SE: A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. N Engl J Med 1998, 339:1882-8.
  30. Waters RE, Singh KP, Roe MT, Lotfi M, Sketch MH Jr., Mahaffey KW, Newby LK, Alexander JH, Harrington RA, Califf RM, Granger CB: Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction. J Am Coll Cardiol 2004, 43:2153-9.
  31. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators Lancet 1999, 354:708-15.
  32. Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N, Neumann FJ, Robertson DH, DeLucca PT, DiBattiste PM, Gibson CM, Braunwald E: Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001, 344:1879-87.
  33. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE, Steward DE, Theroux P, Gibbons RJ, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Smith SC Jr.: ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2002, 40:1366-74.
  34. Rumsfeld JS, Magid DJ, Plomondon ME, O'Brien MM, Spertus JA, Every NR, Sales AE: Predictors of quality of life following acute coronary syndromes. Am J Cardiol 2001, 88:781-4.
  35. Smith SC Jr., Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, Gibbons RJ, Alpert JP, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russell RO: ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001, 37:2215-39.
  36. Warren SG, Brewer DL, Orgain ES: Long-term propranolol therapy for angina pectoris. Am J Cardiol 1976, 37:420-6.
  37. Mortensen OS, Madsen JK, Haghfelt T, Grande P, Saunamaki K, Haunso S, Hjelms E, Arendrup H: Health related quality of life after conservative or invasive treatment of inducible postinfarction ischaemia. DANAMI study group. Heart 2000, 84:535-40.
  38. Pocock SJ, Henderson RA, Clayton T, Lyman GH, Chamberlain DA: Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina. J Am Coll Cardiol 2000, 35:907-14.
  39. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial Lancet 2001, 358:951-7.
  40. Rinfret S, Grines CL, Cosgrove RS, Ho KK, Cox DA, Brodie BR, Morice MC, Stone GW, Cohen DJ: Quality of life after balloon angioplasty or stenting for acute myocardial infarction. One-year results from the Stent-PAMI trial. J Am Coll Cardiol 2001, 38:1614-21.
  41. Zhang Z, Mahoney EM, Stables RH, Booth J, Nugara F, Spertus JA, Weintraub WS: Disease-specific health status after stent-assisted percutaneous coronary intervention and coronary artery bypass surgery: one-year results from the Stent or Surgery trial. Circulation 2003, 108:1694-700.
  42. Kim J, Henderson RA, Pocock SJ, Clayton T, Sculpher MJ, Fox KA: Health-related quality of life after interventional or conservative strategy in patients with unstable angina or non-ST-segment elevation myocardial infarction: one-year results of the third Randomized Intervention Trial of unstable Angina (RITA-3). J Am Coll Cardiol 2005, 45:221-8.