Features of angina pectoris and management of patients with stable ischemic heart disease depending on gender, age and concomitant clinical conditions in the real outpatient practice of cardiologists in Ukraine

Abstract

Objective – to evaluate the features of angina and management of outpatients with stable coronary artery disease (CAD) depending on gender, age and concomitant arterial hypertension (AH), type 2 diabetes mellitus (T2DM), previous myocardial infarction (postMI) and coronary revascularization procedures (CRP) to determine further measures to optimize the management of such patients.
Materials and methods. Subanalysis of subgroups of patients (by age and sex; with AH; T2DM; postMI and history of CRP) of a non-interventional, observational, multicenter prospective study in the real outpatient practice of cardiologists in Ukraine (GO-OD) with the participation of 1529 patients. At the inclusion visit (V1) and during follow-up visits within 3 months, the characteristics of angina and patient management were analyzed. 
Results. The analysis included 1448 patients. In women under 55 years of age, almost 2 times less often, and at the age of 65 and older (65+) 2 times more often than in men, CAD was diagnosed, as well as abdominal type of overweight/obesity (Ov/Ob). Women under 55 years of age were less likely than men to have typical symptoms of angina, and emotional stress was more likely to be a provoking factor for attacks. Beta-blockers (BBs), statins, and angiotensin-converting enzyme inhibitors (ACEIs) were less commonly prescribed to women, and calcium channel blockers (CCBs) were more commonly prescribed. 
There were 39.6% postMI patients and 64.1% had history of CRP at V1. CRP was performed less frequently in patients without MI (p < 0.001). PostMI patients were younger (p < 0.001); more often they were active smokers/ former smokers, had concomitant prediabetes (p = 0.017) / T2DM (p = 0.030). At V1, cholesterol and low-density lipoprotein levels exceeded the target levels. PostMI patients had more frequent angina attacks in the morning (p=0.007), CCS III angina pectoris, and used short-acting nitrates (SAN). In patients with CRP, angina attacks were more often provoked by physical activity, were typical, and less often required SAN (p=0.03). PostMI patients were significantly more likely to receive BB and long-acting nitrates, and patients without MI - CCBs. Approximately 30% of patients in both groups received trimetazidine (TMZ). In patients without MI, ACEIs/sartans and statins were prescribed significantly less frequently. Correction of therapy, regardless of the history of MI, was associated with a decrease in the number of episodes of angina and limitations of daily activity. The number of patients with CCS III angina significantly decreased, but in the postMI group at the final visit there were three times as many such patients.
13.8% of patients had T2DM at V1. They were more often women (p=0.055), twice as rarely young patients (p<0.001); 8 times more often patients with renal dysfunction (p<0.001), and patients with Ov/Ob (p=0.01). In patients with T2DM, angina attacks were more often provoked by emotional stress (p = 0.038) and overeating (p=0.037), angina occurred in the morning (p = 0.001), reached CCS III, p=0.025, and limited daily physical activity more, p<0.001.
71.8% of patients had AH at V1. In hypertensive patients, compared with those without hypertension, pulse pressure (PP) was higher, p<0.001. A significant relationship was found between the age of patients with AH and the level of PP. In patients with non-target BP levels, angina attacks were more likely to be in the form of equivalents (shortness of breath), p=0.017. Almost 30% did not receive statin therapy.  
Conclusions. In the diagnosis and management of outpatients with CAD and stable angina, gender- and age-dependent features of risk factors and clinical course of the disease should be taken into account. 
PostMI patients and patients with CRP have insufficient control of risk factors through lifestyle modification and incomplete drug therapy. 
Concomitant T2DM was more common in patients aged 65+ years, in patients with Ov/Ob, 8 times more often accompanied by renal dysfunction, frequent angina attacks in the morning, angina more often occurred after emotional stress and overeating, significantly limited daily activity, and more often reached CCS III angina pectoris. The pathomorphological features of coronary atherosclerosis in T2DM and the peculiarities of ischemic mechanisms justify the feasibility of combined antianginal therapy with the use of antiischemic drugs (TMZ).
There were 2/3 of patients with AH in the study, 36.3% of patients had high PP, which was associated with a more severe course of angina. In patients with non-target BP, angina attacks were more likely to be in the form of equivalents (shortness of breath). In the management of patients with CAD and concomitant AH, additional mechanisms of myocardial ischemia in hypertrophy should be considered: a reduced ischemia threshold due to a higher oxygen demand, impaired vasomotor and endothelial function of coronary vessels, reduced capillary bed density and capillary wall remodeling. Pathophysiologically, the use of TMZ for anti-ischemic effects on cardiomyocyte levels in all patients with stable CAD is justified. At the final visit, the vast majority of patients in complex therapy received TMZ, which may be a significant component of the effectiveness of angina symptoms control.
The improvement in the clinical course of angina during the study emphasizes the importance of active routine monitoring of patients with CAD and stable angina.