title: Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry.
abstract: OBJECTIVE
  In the era of widespread revascularization and effective antianginals, the prevalence and prognostic effect of anginal symptoms and myocardial ischemia among patients with stable coronary artery disease (CAD) are unknown.
  
  
  OBJECTIVE
  To describe the current clinical patterns among patients with stable CAD and the association of anginal symptoms or myocardial ischemia with clinical outcomes.
  
  
  METHODS
  The Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) registry enrolled outpatients in 45 countries with stable CAD in 2009 to 2010 with 2-year follow-up (median, 24.1 months; range, 1 day to 3 years). Enrollees included 32 105 outpatients with prior myocardial infarction, chest pain, and evidence of myocardial ischemia, evidence of CAD on angiography, or prior revascularization. Of these, 20 291 (63.2%) had undergone a noninvasive test for myocardial ischemia within 12 months of enrollment and were categorized into one of the following 4 groups: no angina or ischemia (n = 13 207 [65.1%]); evidence of myocardial ischemia without angina (silent ischemia) (n = 3028 [14.9%]); anginal symptoms alone (n = 1842 [9.1%]); and angina and ischemia (n = 2214 [10.9%]).
  
  
  METHODS
  Stable CAD.
  
  
  METHODS
  The composite of cardiovascular (CV)-related death or nonfatal myocardial infarction.
  
  
  RESULTS
  Overall, 4056 patients (20.0%) had anginal symptoms and 5242 (25.8%) had evidence of myocardial ischemia on results of noninvasive testing. Of 469 CV-related deaths or myocardial infarctions, 58.2% occurred in patients without angina or ischemia, 12.4% in patients with ischemia alone, 12.2% in patients with angina alone, and 17.3% in patients with both. The hazard ratios for the primary outcome relative to patients without angina or ischemia and adjusted for age, sex, geographic region, smoking status, hypertension, diabetes mellitus, and dyslipidemia were 0.90 (95% CI, 0.68-1.20; P = .47) for ischemia alone, 1.45 (95% CI, 1.08-1.95; P = .01) for angina alone, and 1.75 (95% CI, 1.34-2.29; P < .001) for both. Similar findings were observed for CV-related death and for fatal or nonfatal myocardial infarction.
  
  
  CONCLUSIONS
  In outpatients with stable CAD, anginal symptoms (with or without ischemia on noninvasive testing) but not silent ischemia appear to be associated with an increased risk for adverse CV outcomes. Most CV events occurred in patients without angina or ischemia.
  
  
  BACKGROUND
  isrctn.org Identifier: ISRCTN43070564.
authors.affiliation: Université Paris-Diderot, Sorbonne Paris-Cité, Paris, France2Unit 1148, Institut National de la Santé et de la Recherche Médicale, Paris, France3Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodeling), Department of Cardiology, Hô
authors.forename: Philippe Gabriel
authors.initials: PG
authors.lastname: Steg
authors.affiliation: Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland.
authors.forename: Nicola
authors.initials: N
authors.lastname: Greenlaw
authors.affiliation: Third Division of Cardiology, Medical University of Silesia, Katowice, Poland.
authors.forename: Michal
authors.initials: M
authors.lastname: Tendera
authors.affiliation: Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Tardif
authors.affiliation: Department of Cardiology and Laboratory for Technologies of Advanced Therapies Centre, University Hospital of Ferrara and Maria Cecilia Hospital, Ferrara, Italy9Maria Cecili Hospital, Gruppo Villa Maria Care & Research, Ettore Sansavini Health Science Fou.
authors.forename: Roberto
authors.initials: R
authors.lastname: Ferrari
authors.affiliation: King Abdul-Aziz Cardiac Center, National Guard Health Affairs, Riyadh, Saudi Arabia.
authors.forename: Muayed
authors.initials: M
authors.lastname: Al-Zaibag
authors.affiliation: Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Dorian
authors.affiliation: Heart Institute, Peking University People's Hospital, Beijing, China.
authors.forename: Dayi
authors.initials: D
authors.lastname: Hu
authors.affiliation: State Research Centre for Preventive Medicine, Moscow, Russia.
authors.forename: Svetlana
authors.initials: S
authors.lastname: Shalnova
authors.affiliation: Department of Cardiology, Institute Adrogue, Buenos Aires, Argentina15Department of Cardiology, University Buenos Aires, Buenos Aires, Argentina.
authors.forename: Fernando José
authors.initials: FJ
authors.lastname: Sokn
authors.affiliation: Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland.
authors.forename: Ian
authors.initials: I
authors.lastname: Ford
authors.affiliation: National Heart and Lung Institute, Imperial College, Institute of Cardiovascular Medicine and Sciences, Royal Brompton Hospital, London, England.
authors.forename: Kim M
authors.initials: KM
authors.lastname: Fox
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000787:Angina Pectoris / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000401:mortality; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000209:etiology; D005500:Follow-Up Studies; D008137:Longitudinal Studies; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D017202:Myocardial Ischemia / Q000453:epidemiology / Q000209:etiology / Q000401:mortality; D016017:Odds Ratio; D010045:Outpatients / Q000706:statistics & numerical data; D015995:Prevalence; D011446:Prospective Studies; D012042:Registries