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Long-acting nitrate use before and after revascularization to evaluate angina in chronic coronary syndrome : a case-crossover study from SCAAR

von Koch, Sacharias LU orcid ; Sharma, Tania LU ; Khamis, Ramzi ; Jernberg, Tomas ; James, Stefan ; Omerovic, Elmir ; Zwackman, Sammy ; Sjögren, Johan LU ; Erlinge, David LU orcid and Mohammad, Moman A LU orcid (2026) In The Lancet regional health. Europe 60.
Abstract

BACKGROUND: The ORBITA and ORBITA-2 trials have provided valuable insights into the effects of coronary revascularization in chronic coronary syndrome (CCS). However, uncertainties remain regarding the efficacy of revascularization on symptoms in large real-world populations. To evaluate the efficacy of revascularization, we used dispensed long-acting nitrates as a proxy for the presence of angina.

METHODS: The Swedish Coronary Angiography and Angioplasty Registry (SCAAR) was used to identify all patients with CCS and at least one stenosis ≥50% undergoing angiography between the 1st of January 2014 and the 16th of January 2020. Four groups were defined based on treatment strategy: coronary artery bypass graft (CABG) surgery,... (More)

BACKGROUND: The ORBITA and ORBITA-2 trials have provided valuable insights into the effects of coronary revascularization in chronic coronary syndrome (CCS). However, uncertainties remain regarding the efficacy of revascularization on symptoms in large real-world populations. To evaluate the efficacy of revascularization, we used dispensed long-acting nitrates as a proxy for the presence of angina.

METHODS: The Swedish Coronary Angiography and Angioplasty Registry (SCAAR) was used to identify all patients with CCS and at least one stenosis ≥50% undergoing angiography between the 1st of January 2014 and the 16th of January 2020. Four groups were defined based on treatment strategy: coronary artery bypass graft (CABG) surgery, complete revascularization with percutaneous coronary intervention (PCI), incomplete revascularization with PCI, and no revascularization. As patients in these treatment arms are inherently different, we employed a case-crossover design where each patient served as their own control with data collected during two periods: 1 year before up until angiography and 1-2 years after. This study design inherently controls for time-invariant confounding. The primary outcome was the use of long-acting nitrates defined as a dispensed prescription during the studied periods. Conditional Poisson regression was used to analyse the data.

FINDINGS: For this study, 15,955 patients were eligible. CABG, complete revascularization with PCI, and incomplete revascularization with PCI were associated with a decrease in dispensed prescriptions of long-acting nitrates (from 989/2218 [30.8%] to 156/3207 [4.9%]; risk-ratio (RR): 0.16 [95% confidence interval (CI): 0.13-0.19]), (from 1676/7525 [22.3%] to 966/7525 [12.8%]; RR: 0.58 [95% CI: 0.53-0.62]), and (from 601/2180 [27.6%] to 495/2180 [22.7%]; RR: 0.82 [95% CI: 0.73-0.93]), respectively. No difference was observed for no revascularization (from 864/3043 [28.4%] to 856/3043 [28.1%]; RR: 0.99 [95% CI: 0.90-1.09]).

INTERPRETATION: Revascularization reduces the use of long-acting nitrates in patients with CCS, suggesting angina symptom improvement. CABG appears to provide a more significant effect than PCI, with complete PCI demonstrating greater effectiveness than incomplete revascularization.

FUNDING: This work was supported by The Swedish Heart and Lung Foundation, ALF, Skane University Hospital funds, the Crafoord Foundation and the Swedish Medical Association.

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author
; ; ; ; ; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
epub
subject
keywords
Chronic coronary syndrome, Angina, Percutaneous coronary intervention, Coronary artery bypass graft surgery, Long-acting nitrates
in
The Lancet regional health. Europe
volume
60
article number
101507
pages
10 pages
publisher
Elsevier
external identifiers
  • pmid:41216475
  • scopus:105019924330
ISSN
2666-7762
DOI
10.1016/j.lanepe.2025.101507
language
English
LU publication?
yes
additional info
© 2025 The Author(s).
id
7ba4a52c-84c0-4952-9856-4dc08c6cabf1
date added to LUP
2025-11-13 09:50:33
date last changed
2025-11-14 04:00:30
@article{7ba4a52c-84c0-4952-9856-4dc08c6cabf1,
  abstract     = {{<p>BACKGROUND: The ORBITA and ORBITA-2 trials have provided valuable insights into the effects of coronary revascularization in chronic coronary syndrome (CCS). However, uncertainties remain regarding the efficacy of revascularization on symptoms in large real-world populations. To evaluate the efficacy of revascularization, we used dispensed long-acting nitrates as a proxy for the presence of angina.</p><p>METHODS: The Swedish Coronary Angiography and Angioplasty Registry (SCAAR) was used to identify all patients with CCS and at least one stenosis ≥50% undergoing angiography between the 1st of January 2014 and the 16th of January 2020. Four groups were defined based on treatment strategy: coronary artery bypass graft (CABG) surgery, complete revascularization with percutaneous coronary intervention (PCI), incomplete revascularization with PCI, and no revascularization. As patients in these treatment arms are inherently different, we employed a case-crossover design where each patient served as their own control with data collected during two periods: 1 year before up until angiography and 1-2 years after. This study design inherently controls for time-invariant confounding. The primary outcome was the use of long-acting nitrates defined as a dispensed prescription during the studied periods. Conditional Poisson regression was used to analyse the data.</p><p>FINDINGS: For this study, 15,955 patients were eligible. CABG, complete revascularization with PCI, and incomplete revascularization with PCI were associated with a decrease in dispensed prescriptions of long-acting nitrates (from 989/2218 [30.8%] to 156/3207 [4.9%]; risk-ratio (RR): 0.16 [95% confidence interval (CI): 0.13-0.19]), (from 1676/7525 [22.3%] to 966/7525 [12.8%]; RR: 0.58 [95% CI: 0.53-0.62]), and (from 601/2180 [27.6%] to 495/2180 [22.7%]; RR: 0.82 [95% CI: 0.73-0.93]), respectively. No difference was observed for no revascularization (from 864/3043 [28.4%] to 856/3043 [28.1%]; RR: 0.99 [95% CI: 0.90-1.09]).</p><p>INTERPRETATION: Revascularization reduces the use of long-acting nitrates in patients with CCS, suggesting angina symptom improvement. CABG appears to provide a more significant effect than PCI, with complete PCI demonstrating greater effectiveness than incomplete revascularization.</p><p>FUNDING: This work was supported by The Swedish Heart and Lung Foundation, ALF, Skane University Hospital funds, the Crafoord Foundation and the Swedish Medical Association.</p>}},
  author       = {{von Koch, Sacharias and Sharma, Tania and Khamis, Ramzi and Jernberg, Tomas and James, Stefan and Omerovic, Elmir and Zwackman, Sammy and Sjögren, Johan and Erlinge, David and Mohammad, Moman A}},
  issn         = {{2666-7762}},
  keywords     = {{Chronic coronary syndrome; Angina; Percutaneous coronary intervention; Coronary artery bypass graft surgery; Long-acting nitrates}},
  language     = {{eng}},
  publisher    = {{Elsevier}},
  series       = {{The Lancet regional health. Europe}},
  title        = {{Long-acting nitrate use before and after revascularization to evaluate angina in chronic coronary syndrome : a case-crossover study from SCAAR}},
  url          = {{http://dx.doi.org/10.1016/j.lanepe.2025.101507}},
  doi          = {{10.1016/j.lanepe.2025.101507}},
  volume       = {{60}},
  year         = {{2026}},
}