Angina symptoms in chronic coronary disease often fluctuate, but their long-term patterns have rarely been described. A secondary analysis of the ISCHEMIA trial, published in the Journal of the American College of Cardiology, evaluated how angina evolved over time with invasive versus conservative management.

The analysis included 2,977 participants with baseline angina, randomized to invasive treatment (n=1,505) or conservative management (n=1,472). Angina frequency was measured with the Seattle Angina Questionnaire. Angina Frequency (SAQ-AF) score and recategorized as daily/weekly (0–60 points), monthly (61–99 points), or no angina (100 points). Using ordinal latent trajectory analysis over two years, six pathways were identified in both groups: rapid resolution, gradual resolution, early improvement with persistent infrequent angina, severe angina with improvement, modest angina with minimal change, and severe angina without improvement.

In the invasive arm, rapid resolution (27.1%) and early improvement with infrequent angina (32.1%) were most common. The conservative arm showed higher rates of modest angina with minimal change (42.1%) and fewer cases of rapid resolution (12.8%) or early improvement (10.2%).
The findings demonstrate that patients with chronic coronary disease experience diverse angina trajectories.

A greater proportion of conservatively managed patients followed unfavorable patterns, whereas invasive therapy was associated with faster and more durable relief. Monitoring angina trajectories may help identify patients at risk of persistent symptoms who could benefit from additional therapy.