Predictors of Quality-of-Life Benefit After Percutaneous
Coronary Intervention
John A. Spertus, MD, MPH; Adam C. Salisbury; Philip G. Jones, MS;
Darcy Green Conaway, MD; Randall C. Thompson, MD
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Background—Improving patients’ quality of life is a primary indication for percutaneous coronary intervention (PCI), yet
little is known about patient characteristics associated with greater quality-of-life improvement from the procedure. This
study was conducted to identify patient characteristics associated with quality-of-life benefit after PCI.
Methods and Results—A consecutive series of 1518 patients undergoing PCI in nonacute myocardial infarction settings
were prospectively enrolled into an observational study documenting their postprocedural health status. We examined
univariate and multivariable associations between baseline patient characteristics and quality of life 1 year after the
procedure using the disease-specific Seattle Angina Questionnaire (SAQ) to quantify the impact of patients’ coronary
disease on their quality of life. Baseline angina frequency and physical function were the strongest predictors of quality-of-life
improvement 1 year after PCI. In comparing patients without angina to those experiencing monthly, weekly, and daily angina,
the quality-of-life improvements (mean⫾SEM) were 21.4⫾2.1, 30.7⫾2.2, and 34.6⫾2.6 points greater (P⬍0.001). Patients
with mild, moderate, and severe physical limitation improved 13.8⫾1.9, 20.0⫾2.1, and 13.5⫾3.5 points more than those with
minimal baseline physical limitation (P⬍0.001). These findings were maintained in multivariable models correcting for
baseline differences in demographic, clinical, disease-severity, and health-status variables.
Conclusions—Preprocedural angina frequency is the most important prognostic indicator of quality-of-life improvement
after PCI. Although substantial quality-of-life benefits are attained in most patients with preprocedural angina, more
careful consideration of the potential benefits and risks of the procedure are needed in asymptomatic patients.
(Circulation. 2004;110:3789-3794.)
Key Words: quality of life 䡲 revascularization 䡲 outcomes research 䡲 angina 䡲 coronary disease
T
he most common indication for percutaneous coronary
intervention (PCI) is to improve patients’ quality of life.1
Although numerous studies describe the efficacy of PCI for
angina relief and quality-of-life improvement,2–10 few investigators have sought to define the characteristics of patients
who derive the greatest quality-of-life improvement from the
procedure. Addressing this gap in the literature can help
clinicians identify those patients who are likely to derive the
greatest benefit from the procedure, as well as those in whom
more careful individualization of treatment recommendations
is needed to determine whether the benefits of PCI outweigh
the risks of the procedure.
identify patient characteristics that can be used prospectively
to predict patients’ quality-of-life improvement after PCI.
Methods
Patient Population
The processes of patient recruitment, success, and possible selection
biases have been described previously.11 Data were collected from a
consecutive series of patients undergoing PCI from February 8,
1999, to August 8, 2000, at the Mid-America Heart Institute in
Kansas City, Mo. Among all 2762 patients who underwent PCI
during this period, 5 (0.2%) died during the procedure, 5 (0.2%)
required urgent bypass surgery, 60 (2%) were non–English speaking,
936 (34%) refused to participate, and only 125 (4.5%) could not be
identified and interviewed before discharge. The remaining 1631
patients were recruited into an observational study documenting their
postprocedural health status. Detailed clinical, procedural, and outcomes data, including health-status measures, were collected on each
consenting patient. Health-status questionnaires were administered at
the time of the patients’ procedures and 1 year later. Patients
undergoing PCI for acute myocardial infarction (MI) (n⫽105) were
excluded from these analyses, because the principal indication for
primary revascularization is to extend survival, and improvements in
quality of life are a secondary goal. In addition, procedural data were
See p 3746
To identify preprocedural patient characteristics associated
with quality-of-life improvement after PCI, we consecutively
enrolled patients undergoing the procedure into a prospective
registry that collected baseline demographic, medical,
disease-severity, and health-status variables as well as patients’ 1-year quality of life. This study was designed to
Received July 5, 2004; revision received September 17, 2004; accepted September 29, 2004.
From the University of Missouri–Kansas City, and Mid-America Heart Institute of Saint Luke’s Hospital.
Correspondence to John Spertus, MD, MPH, FACC, Director of Cardiovascular Education and Outcomes Research, 4401 Wornall Rd, Kansas City,
MO 64111. E-mail [email protected]
© 2004 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
DOI: 10.1161/01.CIR.0000150392.70749.C7
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December 21/28, 2004
unavailable for 8 patients. Therefore, our analyses focus on the 1518
patients undergoing PCI for a quality-of-life benefit. Approval from
the Institutional Review Board of Saint Luke’s Hospital was received
before the start of the study.
Outcome Measures
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To define predictors of improved quality of life after PCI, we used
the disease-specific Seattle Angina Questionnaire (SAQ) to measure
patients’ health status (their symptoms, function, and quality of life).
The SAQ is a 19-item instrument that quantifies 5 clinically relevant
domains of coronary disease, including physical limitation, change in
anginal symptoms, angina frequency, satisfaction with treatment,
and quality of life.12 It has well-established validity and reliability
and is more sensitive to clinical change than generic health status
measures.13 In addition, it has been shown to be predictive of 1-year
mortality.14 The Angina Frequency, Physical Function, and Qualityof-Life scales were used to assess patients’ health status. Scores in
these domains range from 0 to 100, where higher scores indicate
better function, fewer symptoms, and better quality of life.
Quality of life is a multidimensional concept that is inversely
related to the discrepancy between how patients are living and their
desired symptoms and function.15,16 Thus, whereas 2 patients may
have similar amounts of angina and physical limitation because of
that angina, their quality of life may differ substantially because of
differing expectations and needs. The greater the current manifestations of their disease deviate from their desired state, the worse their
quality of life. The SAQ Quality-of-Life scale directly assesses
patients’ perceptions of their quality of life by measuring patients’
enjoyment of life, their satisfaction with their current health state,
and their fear of dying or having a heart attack. The SAQ Qualityof-Life domain at 1 year was the primary outcome of interest in this
study.
Clinical and Procedural Assessments of
Disease Severity
The Mid-America Heart Institute has maintained a procedural
database for patients undergoing coronary interventions since 1982.
Using data definitions compatible with the American College of
Cardiology’s National Cardiovascular Data Registry,17 this database
provides a detailed description of the patients’ coronary anatomy, the
technique of revascularization, procedural results, and postprocedural complications.
Follow-Up
Patients were contacted 1 year after their procedure for reassessment
of their quality of life. Before patients were called, queries of the
Social Security Administration Death Master File and local hospital
records were conducted to minimize the likelihood of contacting the
families of deceased patients. Patients were then contacted by
telephone for an interview that included a report of their health
status, interval events, and cardiac procedures outside of the MidAmerica Heart Institute. A minimum of 8 and in some cases more
than 20 attempts were made to contact each patient.
Statistical Analyses
Because PCI is performed to improve patients’ quality of life,
analyses were conducted to identify baseline patient characteristics
associated with changes in quality of life. These included the
demographic, clinical, and disease severity variables listed in Table
1. Baseline health status variables were also incorporated, including
the SAQ Angina Frequency and Physical Limitation scores. To
facilitate interpretation of patients’ health status, baseline Angina
Frequency and Physical Limitation scores were each grouped into 4
ranges: Angina Frequency scores were grouped into daily angina
(SAQ scores⫽0 to 30), weekly angina, (31– 60), monthly angina
(61–99), or no angina (100). Physical Limitation scores were
grouped as severe limitation (0 –25), moderate limitation (26 –50),
mild limitation (51–75), or slight to no limitation (⬎75).
Baseline characteristics associated with 1-year change in quality
of life were evaluated using both univariate and multivariable
TABLE 1. Baseline Demographic, Medical History, and Health
Status Characteristics (nⴝ1518)
Demographics
Age, y
66⫾11
Male
69%
White
95%
Medical history
Previous revascularization
52%
Previous MI
43%
Hypertension
68%
Diabetes
24%
Hyperlipidemia
78%
Chronic obstructive pulmonary disease
9%
Renal insufficiency
7%
Chronic heart failure
7%
Disease severity (No. of diseased vessels)
1
34%
2
30%
3
Ejection fraction
Stent use
36%
50⫾12
86%
Health status
SAQ physical limitation*
69⫾26
SAQ angina frequency*
68⫾26
SAQ quality of life*
56⫾24
*Scale: 1–100; higher score indicates better quality of life.
models. Univariate associations were estimated using linear regression or 1-way ANOVA. To provide a patient-level assessment of
quality-of-life benefit, an additional analysis was conducted to
describe the proportion of patients who experienced a clinically
significant (ⱖ10-point) change in the SAQ Quality-of-Life scale by
baseline frequency of angina and category of physical limitation.
Independent effects were then estimated by the construction of 3
general linear models. The first model included only the patients’
demographic (age, race, and sex) and clinical (previous revascularization, previous MI, hypertension, diabetes, hyperlipidemia, chronic
obstructive pulmonary disease, renal insufficiency, and heart failure)
characteristics. The second model added disease severity characteristics (number of diseased vessels and ejection fraction) to the first
model. The final model included demographic, clinical, and disease
severity characteristics along with the patients’ baseline health status
(SAQ Physical Function and Angina Frequency scores). This order
of model development provides a description of the incremental
contribution from adding disease severity variables to the patient
characteristics (model 2) and health status to patient and disease
severity characteristics (model 3). To describe the strength of
association between model variables and outcome, a coefficient of
multiple determination (R2) was used.
Potential bias introduced by missing data was evaluated using
propensity methods. Propensity scores were generated using logistic
regression to estimate the probability of missing SAQ Quality-ofLife scores (n⫽498), incorporating all baseline demographic and
clinical data as predictors. Models 1 to 3, predicting change in
quality of life on the complete data, were then replicated after
stratifying the population by quintile of propensity score. This allows
a comparison of the models across subgroups of patients who were
increasingly likely to have had missing data. All effect sizes for
patient characteristics, disease severity, and baseline health status
were comparable across propensity strata, and interaction terms by
propensity were all nonsignificant (P⬎0.1). Furthermore, no consis-
Spertus et al
tent trend by likelihood of missing data was observed, suggesting
that any observable selection biases in the results presented are likely
to be minimal.
Descriptive summaries are presented as mean⫾SD for continuous
variables and frequency and percent for categorical variables. Estimated effect sizes from regression models are presented as
mean⫾SEM. Statistical significance was assumed when the 2-sided
probability value was ⱕ0.05. Analyses were performed with SAS
version 8.2 (SAS Institute, Inc) and R version 1.8.0.17a
Results
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Of 1518 eligible patients, 41 (2.7%) died before their 1-year
follow-up. Of the surviving patients, 1020 (69%) completed
the SAQ Quality-of-Life scale both at baseline and at 1-year
follow-up; baseline characteristics are summarized in Table
1. The 498 patients who did not complete questionnaires were
slightly younger (mean age, 64⫾12 versus 66⫾11 years,
P⫽0.005) and more likely to be male (74% versus 69%,
P⫽0.024). They also had slightly less frequent angina (mean
SAQ Angina Frequency score, 71⫾27 versus 68⫾26,
P⫽0.024) and had a slightly lower ejection fraction (48⫾12
versus 50⫾12, P⫽0.021). In addition, heart failure (13%
versus 7%, P⫽0.001), renal insufficiency (10% versus 7%,
P⫽0.04), and chronic obstructive pulmonary disease (13%
versus 9%, P⫽0.006) were more prevalent in the group
without complete follow-up. There were no other significant
differences in the Table 1 variables between those with and
without complete follow-up, and propensity models suggested no significant bias in observed results.
Improvement in Disease-Specific Quality of Life
Overall, PCI conferred substantial benefit to the population of
patients who underwent the procedure. The mean (⫾SD)
SAQ Physical Limitation, Angina Frequency, and Qualityof-Life scores increased by 18⫾25, 24⫾28, and 30⫾26
points, respectively (P⬍0.0001 for all). The large SD of
change highlights the substantial variability of benefit observed for individual patients. Table 2 describes the estimated
effects of different patient characteristics on the 1-year
change in patients’ disease-specific quality of life after PCI.
The first column presents the univariate results, whereas
columns 2 to 4 provide adjusted estimates after controlling
for demographic/clinical, disease severity, and health status
characteristics, respectively.
Univariate models suggest that only age, baseline physical
limitations because of angina, and preprocedural angina
frequency were significantly related to improvements in
quality of life. We observed a mean (⫾SE) improvement of
1.5⫾0.7 points on the SAQ Quality-of-Life scale for each
10-year increase in patient age (P⬍0.05). Compared with
patients with little or no physical limitation (46% of the
population), those with mild physical limitation (27%) experienced a 13.8⫾1.9-point greater quality-of-life improvement
1 year after PCI. Those who were moderately limited (21%)
and those who were severely limited (6%) at baseline
experienced 20⫾2.1- and 13.5⫾3.5-point greater quality-oflife improvements than those with minimal limitations at the
time of their procedures (P⬍0.001). The most important
predictor of quality-of-life benefit from PCI was preprocedural angina frequency. Compared with those without angina
Angina Predicts Quality of Life
3791
at baseline (23% of the population), patients with monthly
(40%), weekly (21%), and daily (10%) angina had 21.4⫾2.1-,
30.7⫾2.2-, and 34.6⫾2.6-point greater disease-specific
quality-of-life improvements (P⬍0.001).
These univariate relationships were largely maintained in
the multivariable models. In the first model, which included
only patient demographic and clinical characteristics, important predictors were age and previous revascularization,
although neither was statistically significant. This model
explained only 0.7% of the observed variance in quality-oflife benefit from PCI. Model 2, in which disease severity
characteristics were added to model 1, explained only 1.2%
of the variance in patients’ quality-of-life benefit after PCI.
In contrast to the minimal association of traditional patient
factors with improvements in quality of life, the third multivariable model reveals that patients’ baseline health status
contributes substantially to the quality-of-life benefits conferred by PCI. This model, including demographic, clinical,
disease severity, and health status variables, explained 25.3%
of the observed variance (R2) in quality-of-life improvements.
The best predictor of quality-of-life improvement was patients’ frequency of angina before PCI. Patients with
monthly, weekly, and daily angina improved 20.0⫾2.4,
28.3⫾2.5, and 32.0⫾3.2 points more than patients without
angina at baseline (P⬍0.001). Patients’ physical limitations
also remained a significant predictor of quality-of-life benefit.
Compared with patients with little preprocedural physical
limitation, those with mild, moderate, and severe limitation
had SAQ Quality-of-Life improvements of 7.8⫾2.0,
12.8⫾2.2, and 4.7⫾3.6 points, respectively (P⬍0.001). Finally, age was also an independent predictor of quality-of-life
benefit from PCI (2.0⫾0.7-point improvement per 10-yeargreater age, P⬍0.01). Figure 1 illustrates the strength of
association between baseline demographic, medical history,
disease severity, and health status data. The gray bars
represent the unadjusted results from those factors listed in
each category (ie, demographic/medical history, disease severity, and health status), and the black bars reveal the
strength to association in the fully adjusted model (ie, model
3 in Table 1).
Proportion of Patients Deriving a Meaningful
Quality-of-Life Benefit From PCI
To provide a more interpretable description of the quality-oflife benefits associated with the presence of angina, we
categorized change in SAQ Quality-of-Life scores into large
deterioration (change ⬍⫺20), moderate deterioration (⫺10 to
⫺20), minimal change (⫺10 to ⫹10), moderate improvement
(⫹10 to ⫹20) and large improvement (⬎⫹20). Figure 2
displays the distribution of change in patients with and
without angina. Thirteen percent of patients without baseline
angina had worse quality of life 1 year later, and 51%
experienced no significant change, compared with 3% and
12% of those who had symptomatic angina at the time of PCI.
Furthermore, only 17% and 19% of patients without angina
experienced moderate and large improvements in their quality of life, compared with 13% and 72% of those with angina.
These results underscore the critical role of angina at the time
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December 21/28, 2004
TABLE 2.
Determinants of Change in Quality of Life After PCI (nⴝ1020)
Mean Estimated Effect (SEM)
Multivariable Models†
Variable
Univariate
Model 1
Model 2
Model 3
Demographics/medical history
Age (per 10 years)
1.2 (0.8)
1.0 (0.8)
Male
⫺2.3 (1.7)
1.5 (0.7)†
⫺2.4 (1.8)
⫺3.0 (1.9)
White
⫺2.6 (3.9)
⫺3.5 (4.0)
⫺3.1 (4.0)
1.3 (3.7)
0.8 (1.6)
1.7 (1.8)
0.8 (1.9)
⫺2.9 (1.8)
Previous revascularization
2.0 (0.7)‡
⫺1.0 (1.8)
Previous MI
⫺0.5 (1.6)
⫺1.2 (1.8)
⫺1.4 (1.8)
⫺0.3 (1.7)
Hypertension
⫺0.6 (1.7)
⫺0.7 (1.8)
⫺1.0 (1.8)
⫺1.2 (1.7)
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Diabetes
⫺1.3 (1.9)
⫺1.5 (2.0)
⫺1.8 (2.0)
⫺1.8 (1.8)
Hyperlipidemia
⫺0.1 (1.9)
⫺0.5 (2.1)
⫺0.9 (2.1)
⫺1.3 (1.9)
Chronic obstructive pulmonary disease
0.3 (2.8)
0.0 (3.0)
⫺0.1 (3.0)
2.4 (3.0)
Renal insufficiency
0.9 (3.1)
0.2 (3.2)
⫺0.1 (3.2)
0.1 (3.3)
Chronic heart failure
1.0 (3.1)
⫺0.4 (3.3)
⫺0.8 (3.4)
0.4 (3.4)
Disease severity (No. of diseased vessels)
⫺
1
NA
2
3.4 (2.0)
3
4.4 (1.9)
Ejection fraction ⱕ40
0.8 (2.1)
⫺
3.0 (2.1)
NA
⫺
2.4 (2.0)
4.4 (2.2)
1.9 (2.1)
0.3 (2.3)
⫺0.3 (2.2)
Baseline health status
SAQ physical limitation§
None to slight
§
⫺
NA
NA
⫺
Mild
13.8 (1.9)
7.8 (2.0)
Moderate
20.0 (2.1)
12.8 (2.2)
Severe
13.5 (3.5)
4.7 (3.6)
SAQ angina frequency§
None
§
⫺
NA
NA
⫺
Monthly
21.4 (2.1)
20.0 (2.4)
Weekly
30.7 (2.2)
28.3 (2.5)
Daily
34.6 (2.6)
Model R 2
NA
32.0 (3.2)
0.7%
1.2%
25.3%
*Model 1 contains demographic and clinical characteristics only; Model 2 adds disease severity;
and Model 3 adds baseline health status.
†P⬍0.05, ‡P⬍0.01, §P⬍0.001.
of PCI as a predictor of procedural benefit, from the patients’
perspectives.
Discussion
To identify preprocedural patient characteristics associated with
quality-of-life improvement from PCI, we prospectively enrolled a large, consecutive cohort of patients undergoing the
procedure. We found that the only baseline characteristics
independently associated with quality-of-life benefits 1 year
after PCI were age, physical function, and angina frequency. The
strongest predictor of benefit was preprocedural angina. Those
with monthly, weekly, and daily angina experienced 21-, 31-,
and 35-point greater improvements on the SAQ Quality-of-Life
scale compared with those without angina. In fact, fewer than
36% of patients without angina had a clinically significant
improvement in their quality of life, compared with more than
85% of those with at least some angina.
These insights provide an important complement to
existing knowledge of patient outcomes after PCI. Although many investigators have described the impact of
PCI on patient health status,2–10 only a few studies have
examined which patient characteristics are most strongly
associated with the quality-of-life benefits from PCI. In
contrast, most studies have focused on cross-sectional
associations that included patients’ symptoms at the time
of follow-up and their influence on quality of life. For
example, a 106-patient study by Permanyer-Miralda and
colleagues18 demonstrated that residual angina after PCI
was the most important determinant of lower 3-year
quality of life. Similarly, Pocock and colleagues2,19 demonstrated important associations between angina, breathlessness, and physical function with 1-year quality of life.
However, none of these studies focused primarily on
changes in quality of life or patients’ preprocedural char-
Spertus et al
Figure 1. Association of baseline variables with changes in SAQ
Quality of Life at 12 months. Percentage of the observed variance in quality of life explained by baseline patient
characteristics.
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acteristics associated with greater quality-of-life benefits
from the procedure.
One study examined preprocedural predictors of qualityof-life benefit. Nash and colleagues20 identified baseline
Short Form-36 Physical and Mental Component Summary
scores as the most important independent predictors of these
domains at follow-up. By examining predictors of 6-month
general health status scores, as opposed to change scores,
these investigators modeled patients’ follow-up health status
rather than the benefit they received from the procedure. We
believe that the present analysis is more clinically relevant
and extends the previous study by incorporating a more
robust characterization of patients’ cardiac symptoms and
function at the time of their PCI.
We believe that our data suggest an important opportunity
to initiate a process for quantifying the appropriateness of
PCI procedures. Since its introduction in the late 1970s, the
frequency of PCI has grown substantially, with more than
1 200 000 procedures currently being performed annually in
the United States alone.21 Furthermore, a 6-fold variation in
its use has been documented among Medicare beneficiaries.22
Given the prevalence, expense, and variability of PCI, much
work is needed to create tools that quantify the indications or
“appropriateness” of PCI so that systematic efforts at quality
Angina Predicts Quality of Life
3793
assessment and improvement can be pursued. Although
traditional “disease severity” variables such as ejection fraction, severity of coronary disease, etc, have been used
previously to examine the appropriateness of PCI,23,24 they
predict little of the quality-of-life benefits obtained by patients after PCI. Thus, although they may be applicable to
mortality outcomes, they do not reflect the patients’ perspectives of the quality-of-life benefits from PCI. These study
results suggest that angina symptoms should be one of the
criteria for classifying an appropriate intervention and that
greater scrutiny of the appropriateness of PCI in the 23% of
asymptomatic patients should be considered.
Several potential limitations of this study should be considered. First, this was a single-center study, and it is possible
that unique characteristics of the patients, the physicians, or
the institution may limit the generalizability of these results.
Further research should examine predictors of quality-of-life
improvement in larger, multicenter studies. An additional
concern is that only 69% of the patients involved in baseline
analyses completed 1-year follow-up. However, lower
follow-up is not uncommon in consecutive registries and may
be offset by the benefit of a cohort that is more representative
of the general patient population undergoing PCI than a
secondary analysis of patients enrolled in a clinical trial.
Although conducting these analyses in the context of clinical
trials may allow higher rates of follow-up, the selection bias
of who gets enrolled into the clinical trials may significantly
offset this benefit.25 Furthermore, a propensity analysis based
on the likelihood of missing data suggested that no significant
biases were introduced into our documented association
between worse preprocedural health status and greater
quality-of-life benefits from the procedure. An additional
limitation is that some patients undergoing PCI were not
included in the registry. Although approached to participate,
34% refused. Although these patients may have introduced a
bias in our results, current ethics of informed consent mandate obtaining patient approval, and there is no a priori reason
to expect that the relationships defined by these analyses
would be unique to only those who agreed to participate in
our study.
Figure 2. Distribution of quality-of-life
benefit by presence of angina. Distribution of SAQ quality of life change in
patients with and without angina.
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December 21/28, 2004
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Although considered good for models of health status
outcomes, our best models still explained only 25.3% of the
variation in patients’ quality-of-life benefits from PCI. Thus,
some patients with no baseline angina may derive a substantial quality-of-life benefit from PCI, and conversely, some
with daily angina may receive little benefit. Clinical judgment
should dominate decisions on the application of PCI, although much greater benefit should be anticipated among
those with greater symptomatic burden. Further research to
define additional demographic, clinical, physiological, and
genetic factors associated with patients’ quality-of-life benefits after PCI is warranted. Finally, it is possible that patients
who received little quality-of-life benefit from the procedure
may have done worse with medical therapy or that PCI could
have prevented future worsening of their health status. Our
findings should not be interpreted as a suggestion that PCI is
inappropriate for patients with little baseline angina or good
physical function. Rather, more careful consideration of the
potential benefits versus risks of the procedure is necessary
for minimally symptomatic patients.
This study provides an important step toward understanding the predictors of quality-of-life improvement after PCI. It
is hoped that this information will allow clinicians to prospectively understand the degree of postprocedural benefit
patients are likely to experience, thereby supporting medical
decision-making and augmenting physicians’ ability to convey anticipated benefits to patients. This is an especially
important contribution in light of evidence that patients often
overestimate the likely benefits of PCI.26 Although further
research should replicate this work, it appears that substantially less benefit, from the patients’ perspectives, should be
anticipated when PCI is performed in asymptomatic
individuals.
Acknowledgments
This project was supported in part by an unrestricted grant from
Searle Pharmaceuticals and in part by grant R-01-HS-11282-01 from
the Agency for Healthcare Research and Quality of Life.
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Predictors of Quality-of-Life Benefit After Percutaneous Coronary Intervention
John A. Spertus, Adam C. Salisbury, Philip G. Jones, Darcy Green Conaway and Randall C.
Thompson
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Circulation. 2004;110:3789-3794; originally published online December 13, 2004;
doi: 10.1161/01.CIR.0000150392.70749.C7
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