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Original Articles

Economic Impact of Angina After an Acute Coronary Syndrome

Insights From the MERLIN-TIMI 36 Trial

Suzanne V. Arnold, MD, MHA; David A. Morrow, MD, MPH; Yang Lei, MS; David J. Cohen, MD, MSc; Elizabeth M. Mahoney, ScD; Eugene Braunwald, MD and Paul S. Chan, MD, MSc

From the Saint Luke’s Mid America Heart Institute (S.V.A., Y.L., D.J.C., E.M.M., P.S.C.), Kansas City, Mo; and the TIMI Study Group (D.A.M., E.B.), Brigham and Women’s Hospital, Boston, Mass.

Correspondence to Paul S. Chan, MD, MSc, Saint Luke’s Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO 64111. E-mail pchan{at}cc-pc.com

Received October 16, 2008; accepted April 14, 2009.

Background— Angina in patients with coronary artery disease is associated with worse quality of life; however, the relationship between angina frequency and resource utilization is unknown.

Methods and Results— Using data from the MERLIN-TIMI 36 trial, we assessed the association between the extent of angina after an acute coronary syndrome (ACS) and subsequent cardiovascular resource utilization among 5460 stable outpatients who completed the Seattle Angina Questionnaire at 4 months after an ACS and who were then followed for an additional 8 months. Angina frequency was categorized as none (score, 100; 2739 patients), monthly (score, 61 to 99; 1608 patients), weekly (score, 31 to 60; 854 patients), and daily (score, 0 to 30; 259 patients). Multivariable regression models evaluated the association between angina frequency and overall costs attributable to cardiovascular hospitalizations, outpatient visits and procedures, and medications. As compared with no angina, overall costs increased in a graded fashion with higher angina frequency—no angina, $2928 (reference); monthly angina, $3909 (adjusted relative cost ratio, 1.29; 95% CI, 1.21 to 1.39); weekly angina, $4558 (adjusted relative cost ratio, 1.52; 95% CI, 1.48 to 1.67); and daily angina, $6949 (adjusted relative cost ratio, 2.32; 95% CI, 2.01 to 2.69; P for trend <0.001). Differences in costs were attributable primarily to higher rates of ACS hospitalization and coronary revascularization among patients with more severe angina.

Conclusion— Among stable outpatients after ACS, a direct graded relationship was found between higher angina frequency and healthcare costs. As compared with patients without angina, patients with daily angina had a >2-fold increase in resource utilization and incremental costs of $4000 after 8 months of follow-up.

Key Words: angina • cost and cost analysis • health status

Guest Editor for this article was Paul A. Heidenreich, MD.

The online-only Data Supplement can be found at http://circoutcomes.ahajournals.org/cgi/content/full/10.1161/CIRCOUTCOMES.108.829523/DC1.