Assessing the Prognostic Value of Serial Seattle Angina Questionnaire Scores in Chronic Coronary Disease

Abstract

Background

Patient-centered prognostic assessment in chronic coronary disease (CCD) is vital for treatment optimization. While the Seattle Angina Questionnaire Summary Score (SAQ-SS) correlates with clinical outcomes, clinicians lack guidance on how to weigh prior, current, or change in scores, and whether prognostic significance varies by revascularization strategy.

Methods

The ISCHEMIA trial (2012–2019) was a global, multicenter, randomized controlled trial. This secondary analysis evaluated the prognostic value of serial SAQ-SS assessments. The SAQ-SS ranges from 0 to 100, with higher scores indicating better health status. To simulate routine clinical care, the follow-up in ISCHEMIA was equated to outpatient clinic visits— we defined the 3-month SAQ-SS as the “prior” score and the 6-month assessment as the “current” score in “clinic.” Analyses were stratified by treatment strategy: conservative management and invasive management with revascularization. Cox proportional hazards models assessed the association of the prior score, the current score, and the change in scores with ISCHEMIA’s primary composite endpoint (cardiovascular death, myocardial infarction, hospitalization for unstable angina, heart failure, and resuscitated cardiac arrest), adjusting for 17 clinical covariates.

Results

This analysis included 3,405 participants (1,965 conservative management: 77.4% male, mean age 64.3 years ± 9.5; 1,440 invasive management: 77.6% male, mean age 64.0 years ± 9.4). Over 3.2 years of median follow-up, 215 (11.0%) and 96 (6.7%) participants in the conservative and invasive cohorts, respectively, experienced the primary composite endpoint. Higher prior, current, and change SAQ-SS were each independently associated with a lower risk of cardiovascular events. In the conservative cohort, each 5-point increase in the current SAQ-SS was associated with a 7% lower risk of the primary endpoint (HR 0.93; 95% CI 0.90–0.96); in the invasive cohort, the association was 9% (HR 0.91; 95% CI 0.86–0.96).

Conclusions

In patients with CCD, the most recent SAQ-SS is the strongest health status predictor of future cardiovascular events. Serial SAQ-SS assessments provide a practical, dynamic, and patient-centered approach for updating prognosis in CCD management.

Introduction

While cardiac stress testing has long been the cornerstone of risk-stratification in chronic coronary disease (CCD), recent guidelines and initiatives—including the 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of CCD and the Choosing Wisely campaign—discourage frequent or routine follow-up testing.^{1, 2} These recommendations necessitate alternative, evidence-based strategies for monitoring outpatient risk.

Patient-reported outcomes (PROs), which systematically assess patients’ health status (symptoms, physical function, and quality of life (QoL)), are increasingly being integrated into routine clinical care and offer a promising solution.³ In addition to providing a standardized assessment that overcomes inter-clinician variability, the Seattle Angina Questionnaire (SAQ) has been shown to be independently associated with subsequent death and myocardial infarction.^4–9 These prior studies, however, only examined the association at a single point in time. If the SAQ is to be used effectively during longitudinal follow-up, it remains unclear whether clinicians should prioritize the patients’ prior score, current score, or the interval change between visits. Furthermore, it is unknown whether the prognostic significance of these serial scores differs between patients managed medically and those who have undergone recent revascularization.

To address these knowledge gaps, we examined the prognostic value of serial SAQ summary scores (SAQ-SS) with the ISCHEMIA trial. Rather than developing a complex multivariable risk-prediction model that may be difficult to implement in practice, we focused on comparing the strength of association between serial SAQ-SS assessments and ISCHEMIA’s primary composite endpoint (cardiovascular death, myocardial infarction, resuscitated sudden cardiac death, heart failure or unstable angina admissions) among patients managed with both conservative and invasive strategies. Demonstrating a clear association between specific serial SAQ metrics and clinical events may further clarify the value of PROs to clinicians and guide them on which scores are most prognostically informative for tailoring medical therapy or determining the need for revascularization.¹⁰

Methods

The design, patient characteristics, and primary results of the ISCHEMIA trial have been previously described; all data supporting these analyses are available upon request from BioLINCC.^10–12 Briefly, ISCHEMIA was an open-label, international trial of patients with stable CCD and at least moderate ischemia randomized to an initial treatment strategy of either conservative or invasive management. Both cohorts received optimal medical therapy; the invasive strategy included angiography and coronary revascularization, if feasible, with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). This secondary analysis used the ISCHEMIA primary composite endpoint—cardiovascular death, myocardial infarction (MI), hospitalization for unstable angina, heart failure, and resuscitated cardiac arrest—as the primary outcome.¹⁰ The study was approved by the NYU Grossman School of Medicine Institutional Review Board and by the review board of each participating site; all patients provided written informed consent.

Health Status Assessment

Health status was assessed using the 7-item SAQ (SAQ-7) at randomization, 1.5, 3 and 6 months, and then every 6 months thereafter until study termination.¹¹ The SAQ-7 measures three domains—Angina Frequency, Physical Limitations, and Quality of Life. The SAQ Summary Score aggregates these domains into a single measure of coronary-specific health status. Scores range from 0–100, where higher scores indicate fewer symptoms and superior health status. Clinical interpretability was supported by categorizing scores into ranges: 0 to 24 (poor health status), 25 to 49 (fair health status), 50 to 74 (good health status) and 75 to 100 (excellent health status). Regarding Angina Frequency: 0–30 (daily), 31–60 (weekly), 61–99 (monthly), and 100 (no angina). The SAQ-7 has previously been validated and shown to be reliable and sensitive to changes in clinical status.¹³

Statistical Analysis

This analysis adopted the perspective of an outpatient clinician evaluating stable CCD using current and recent SAQ-SS assessments. The ISCHEMIA trial prespecified participants would follow up at regular intervals; leveraging this framework, the 3-month follow-up was defined as the ‘prior’ clinic visit and the 6-month follow-up as the ‘current’ visit, with the latter serving as the baseline for subsequent clinical events. To ensure clinical relevance, cohorts were analyzed separately. The invasive cohort only included patients having undergone revascularization prior to the 3-month visit so that the prognostic significance of the SAQ after recent revascularization could be assessed. Similarly, the conservative cohort only included patients not having undergone revascularization prior to the 6-month visit (Figure 1).

Figure 1. Study Flow Chart.

Consolidated flow of the study population from randomization through the 6-month landmark. The primary outcome was a composite of cardiovascular death, myocardial infarction (MI), hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, which also served as the primary endpoint of the ISCHEMIA trial.

Abbreviations: QoL = Quality of Life; SAQ-7 = 7-item Seattle Angina Questionnaire; Revasc = coronary revascularization

Baseline patient characteristics were described and categorized by participants’ 6-month SAQ-SS: <50 (poor-to-fair health status), 50–74 (good health status), or 75–100 (excellent health status). The primary independent variable was the SAQ-SS, and the primary outcome was time to occurrence of the primary endpoint used in the ISCHEMIA trial (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). Kaplan-Meier methods were used to estimate the time to the primary endpoint, occurring between 6 and 48 months, stratified by prior, current and change in SAQ-SS. Change scores were categorized as: ≤ −10 (large deterioration), > −10 to ≤ −5 (small but clinically important deterioration), > −5 to < 5 (stable), ≥ 5 to < 10 (small but important improvement), and ≥10 (large improvement).

Cox proportional hazards models were used to estimate the association between 3-month, 6-month, and change SAQ-SS with clinical outcomes. Unadjusted models would be most relevant for routine clinical practice. Still, we included multivariable models adjusted for 17 a priori covariates—age, sex, region, race, hypertension, body mass index, diabetes, smoking status, prior MI, prior PCI, prior coronary artery bypass grafting (CABG), prior heart failure, left ventricular ejection fraction, prior stroke, history of cerebrovascular disease, prior peripheral vascular disease (PAD), and estimated glomerular filtration rate (eGFR)—to evaluate whether the SAQ-SS provides unique information beyond these established risk factors. However, rather than develop a parsimonious risk-prediction model that would likely be hard to implement in clinical practice, the goal was to provide a more qualitative sense of risk that clinicians could consider during a patient visit.

To determine which metric best informs prognosis, we compared three initial models—the prior score, current score, and change score—followed by two combined models: (1) the prior and current score, (2) the current and change score.

Nonlinear associations between the SAQ-SS and clinical outcomes were explored using restricted cubic splines. Spline terms were non-significant (p>0.29 for all), except for the SAQ-SS change score (p=0.04). However, to prioritize clinical interpretability, particularly because SAQ-SS change score proved to not be the primary predictor of interest, all associations were modeled as linear, and hazard ratios (HRs) were scaled per 5-point increment.

Missing data were minimal (<1.3% for any single variable and 3.2% participants missing any variable), treated as missing at random, and addressed via single imputation—missing values were replaced with the mean for continuous variables or mode for categorical variables. Analyses were performed using SAS (v9.4) and R (v4.3.3).¹⁴

Results

Among the 1,965 participants in the conservative management cohort, 27% were from North America, 77% were male, and 73% were white, with a mean age of 64 ± 9.5 years and a mean body mass index (BMI) of 29 ± 5.4 kg/m². Of the 1440 patients in the invasive management cohort, 24% were from North America, 78% were male, and 72% were white, with a mean age of 64 ± 9.4 years and a mean BMI of 29 ± 4.8. Additional patient clinical characteristics are provided in Table 1; characteristics stratified by SAQ-SS change scores are available in Table S1.

Table 1:

Patient Characteristics

Conservative Management Cohort
Variable	Overall, N = 1,965*	Poor to Fair SAQ-SS Score (<50), N = 91*	Good SAQ_SS Score (<75), N = 359*	Excellent SAQ-SS Score (75–100), N = 1,515*
Age, years
Mean±SD	64.3±9.5	63.5±9.9	63.7±9.7	64.5±9.5
Sex
Male	1,521/1,965(77.4%)	62/91(68.1%)	241/359(67.1%)	1,218/1,515(80.4%)
Female	444/1,965(22.6%)	29/91(31.9%)	118/359(32.9%)	297/1,515(19.6%)
Race
White	1,419/1,940(73.1%)	80/91(87.9%)	268/356(75.3%)	1,071/1,493(71.7%)
Black	81/1,940(4.2%)	3/91(3.3%)	14/356(3.9%)	64/1,493(4.3%)
Asian	431/1,940(22.2%)	8/91(8.8%)	71/356(19.9%)	352/1,493(23.6%)
American Indian Alaska	4/1,940(0.2%)	0/91(0.0%)	2/356(0.6%)	2/1,493(0.1%)
Hawaiian	5/1,940(0.3%)	0/91(0.0%)	1/356(0.3%)	4/1,493(0.3%)
Region
North America	530/1,965(27.0%)	15/91(16.5%)	72/359(20.1%)	443/1,515(29.2%)
Europe	714/1,965(36.3%)	47/91(51.6%)	144/359(40.1%)	523/1,515(34.5%)
Asia	469/1,965(23.9%)	19/91(20.9%)	90/359(25.1%)	360/1,515(23.8%)
Latin America	212/1,965(10.8%)	6/91(6.6%)	44/359(12.3%)	162/1,515(10.7%)
Other	40/1,965(2.0%)	4/91(4.4%)	9/359(2.5%)	27/1,515(1.8%)
BMI, kg/m2
Mean±SD	28.9±5.4	31.2±5.7	29.4±5.7	28.7±5.3
Hypertension	1,484/1,957(75.8%)	80/91(87.9%)	281/358(78.5%)	1,123/1,508(74.5%)
Diabetes	763/1,965(38.8%)	36/91(39.6%)	144/359(40.1%)	583/1,515(38.5%)
Smoking Status
Never Smoked	800/1,965(40.7%)	28/91(30.8%)	147/359(40.9%)	625/1,515(41.3%)
Former Smoker	909/1,965(46.3%)	41/91(45.1%)	172/359(47.9%)	696/1,515(45.9%)
Current Smoker	256/1,965(13.0%)	22/91(24.2%)	40/359(11.1%)	194/1,515(12.8%)
Prior MI	404/1,958(20.6%)	20/91(22.0%)	83/357(23.2%)	301/1,510(19.9%)
Prior PCI	418/1,963(21.3%)	18/91(19.8%)	84/359(23.4%)	316/1,513(20.9%)
Prior CABG	79/1,965(4.0%)	8/91(8.8%)	18/359(5.0%)	53/1,515(3.5%)
Prior heart failure	72/1,965(3.7%)	11/91(12.1%)	21/359(5.8%)	40/1,515(2.6%)
Left ventricular ejection fraction, %
Mean±SD	60.0±8.4	58.5±9.0	59.7±8.8	60.1±8.2
Prior stroke	54/1,965(2.7%)	2/91(2.2%)	13/359(3.6%)	39/1,515(2.6%)
History of cerebrovascular disease	137/1,965(7.0%)	10/91(11.0%)	33/359(9.2%)	94/1,515(6.2%)
History of peripheral vascular disease	76/1,959(3.9%)	7/91(7.7%)	15/357(4.2%)	54/1,511(3.6%)
CKD stage by eGFR
1	857/1,965(43.6%)	30/91(33.0%)	151/359(42.1%)	676/1,515(44.6%)
2	869/1,965(44.2%)	47/91(51.6%)	152/359(42.3%)	670/1,515(44.2%)
3a	185/1,965(9.4%)	12/91(13.2%)	35/359(9.7%)	138/1,515(9.1%)
3b & worse	54/1,965(2.7%)	2/91(2.2%)	21/359(5.8%)	31/1,515(2.0%)
Degree of ischemia
None	111/1,943(5.7%)	4/91(4.4%)	26/352(7.4%)	81/1,500(5.4%)
Mild	154/1,943(7.9%)	8/91(8.8%)	26/352(7.4%)	120/1,500(8.0%)
Moderate	681/1,943(35.0%)	38/91(41.8%)	121/352(34.4%)	522/1,500(34.8%)
Severe	997/1,943(51.3%)	41/91(45.1%)	179/352(50.9%)	777/1,500(51.8%)
Invasive Management Cohort
Variable	Overall, N = 1,440*	Poor to Fair SAQ-SS Score (<50), N = 35*	Good SAQ-SS Score (<75), N = 174*	Excellent SAQ-SS Score (75–100), N = 1,231*
Age, years
Mean±SD	63.5±9.4	64.9±10.3	63.5±9.4	63.5±9.3
Sex
Male	1,117/1,440(77.6%)	22/35(62.9%)	124/174(71.3%)	971/1,231(78.9%)
Female	323/1,440(22.4%)	13/35(37.1%)	50/174(28.7%)	260/1,231(21.1%)
Race
White	1,027/1,431(71.8%)	26/35(74.3%)	111/173(64.2%)	890/1,223(72.8%)
Black	58/1,431(4.1%)	4/35(11.4%)	14/173(8.1%)	40/1,223(3.3%)
Asian	339/1,431(23.7%)	5/35(14.3%)	48/173(27.7%)	286/1,223(23.4%)
American Indian Alaska	3/1,431(0.2%)	0/35(0.0%)	0/173(0.0%)	3/1,223(0.2%)
Hawaiian	4/1,431(0.3%)	0/35(0.0%)	0/173(0.0%)	4/1,223(0.3%)
Region
North America	349/1,440(24.2%)	8/35(22.9%)	40/174(23.0%)	301/1,231(24.5%)
Europe	496/1,440(34.4%)	16/35(45.7%)	46/174(26.4%)	434/1,231(35.3%)
Asia	391/1,440(27.2%)	6/35(17.1%)	65/174(37.4%)	320/1,231(26.0%)
Latin America	173/1,440(12.0%)	4/35(11.4%)	19/174(10.9%)	150/1,231(12.2%)
Other	31/1,440(2.2%)	1/35(2.9%)	4/174(2.3%)	26/1,231(2.1%)
BMI, kg/m2
Mean±SD	28.6±4.8	29.4±5.3	29.0±5.5	28.5±4.7
Hypertension	1,104/1,438(76.8%)	27/35(77.1%)	140/174(80.5%)	937/1,229(76.2%)
Diabetes	575/1,440(39.9%)	19/35(54.3%)	81/174(46.6%)	475/1,231(38.6%)
Smoking Status
Never Smoked	601/1,439(41.8%)	21/35(60.0%)	82/173(47.4%)	498/1,231(40.5%)
Former Smoker	662/1,439(46.0%)	8/35(22.9%)	69/173(39.9%)	585/1,231(47.5%)
Current Smoker	176/1,439(12.2%)	6/35(17.1%)	22/173(12.7%)	148/1,231(12.0%)
Prior MI	310/1,439(21.5%)	6/35(17.1%)	49/174(28.2%)	255/1,230(20.7%)
Prior PCI	310/1,440(21.5%)	11/35(31.4%)	36/174(20.7%)	263/1,231(21.4%)
Prior CABG	56/1,440(3.9%)	3/35(8.6%)	10/174(5.7%)	43/1,231(3.5%)
Prior heart failure	69/1,440(4.8%)	2/35(5.7%)	8/174(4.6%)	59/1,231(4.8%)
Left ventricular ejection fraction, %
Mean±SD	60.4±8.0	59.9±9.5	59.8±8.4	60.5±7.9
Prior stroke	49/1,440(3.4%)	1/35(2.9%)	8/174(4.6%)	40/1,231(3.2%)
History of cerebrovascular disease	116/1,440(8.1%)	2/35(5.7%)	15/174(8.6%)	99/1,231(8.0%)
History of peripheral vascular disease	64/1,439(4.4%)	1/35(2.9%)	7/174(4.0%)	56/1,230(4.6%)
CKD stage by eGFR
1	643/1,440(44.7%)	13/35(37.1%)	73/174(42.0%)	557/1,231(45.2%)
2	643/1,440(44.7%)	14/35(40.0%)	84/174(48.3%)	545/1,231(44.3%)
3a	116/1,440(8.1%)	4/35(11.4%)	12/174(6.9%)	100/1,231(8.1%)
3b & worse	38/1,440(2.6%)	4/35(11.4%)	5/174(2.9%)	29/1,231(2.4%)
Degree of ischemia
None	60/1,422(4.2%)	3/35(8.6%)	9/173(5.2%)	48/1,214(4.0%)
Mild	85/1,422(6.0%)	3/35(8.6%)	12/173(6.9%)	70/1,214(5.8%)
Moderate	501/1,422(35.2%)	16/35(45.7%)	63/173(36.4%)	422/1,214(34.8%)
Severe	776/1,422(54.6%)	13/35(37.1%)	89/173(51.4%)	674/1,214(55.5%)

^*n/N(%).BMI denotes Body Mass Index; MI denotes Myocardial Infarction; PCI denotes Percutaneous Coronary Intervention; CABG denotes Coronary Artery Bypass Grafting; SD denotes Standard Deviation; CKD denotes Chronic Kidney Disease; eGFR denotes estimated Glomerular Filtration Rate.

Associations between Health Status & Clinical Events in the Conservative Management Cohort

Among conservatively managed patients, a higher SAQ-SS demonstrated greater event-free survival (Figure 2); Kaplan-Meier curves for 3-month and change-score assessments across both populations can be found in the supplement (Figures S1–2). When analyzed individually, higher prior and current SAQ-SS were each associated with a significantly lower risk of clinical events (HR 0.93 per 5-point increase for both; 95% CI, 0.90–0.97 and 0.90–0.96, respectively; Figure 3a). The change in SAQ-SS was not significantly associated with subsequent clinical events (HR 0.97 per 5-point increase; 95% CI 0.92, 1.02). Following multivariable adjustment, the associations remained largely unchanged (Figure 3b).

Figure 2: Kaplan-Meier Curves for the Primary Composite Outcome.

Cumulative incidence of the primary outcome stratified by 6-month (current) Seattle Angina Questionnaire Summary Score (SAQ-SS) categories: Fair (<50), Good (50 to <75), and Excellent (≥75). Panel (a) represents participants randomized to the conservative strategy; Panel (b) represents participants randomized to the invasive strategy who underwent revascularization. The primary outcome was a composite of cardiovascular death, MI, hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest.

Figure 3: Association Between Serial SAQ-SS and Clinical Outcomes.

Hazard ratios (HR) for the primary composite outcome per 5-point increment in SAQ-SS. “Prior” refers to the 3-month assessment, and “current” refers to the 6-month assessment. (a) Unadjusted and (b) adjusted models for the conservative management cohort. (c) Unadjusted and (d) adjusted models for the invasive management cohort (restricted to those revascularized prior to the 3-month assessment). Adjusted models included 17 clinical covariates (see Methods).

Abbreviations: HR = Hazard Ratio; CI = Confidence Interval

In joint models including the current SAQ-SS alongside either prior or change scores, only the current score retained independent prognostic significance (HR 0.94; 95% CI, 0.90–0.99 and HR 0.92; 95% CI, 0.89–0.96, respectively). Prior scores and interval changes were no longer associated with clinical events once the current score was included in the model (Figure 3a). Multivariable adjustment resulted in minimal attenuation of the current score’s prognostic value (Figure 3b).

Associations between Health Status and Clinical Events in the Invasive Management Cohort

Among invasively managed patients, higher SAQ-SS categories were similarly associated with a lower incidence of clinical events; this relationship was most pronounced in patients with scores <50 (Figure 2). Unadjusted Cox regression demonstrated that higher prior (HR 0.92 per 5-point increase; 95% CI, 0.87–0.98) and current (HR 0.91 per 5-point increase; 95% CI, 0.86–0.96) SAQ-SS assessments were associated with reduced risk (Figure 3c). Similar to the conservative cohort, 3-month change scores were not associated with clinical events (HR 0.97; 95% CI, 0.90–1.04), and multivariable adjustment did not significantly alter these findings (Figure 3d).

When prior and change scores were modeled with the current SAQ-SS, the current score demonstrated a stronger association with prognosis than the other two metrics (Figure 3c). This association remained robust after multivariable adjustment (Figure 3d).

Discussion

Understanding the prognosis of patients with CCD is critical when considering more aggressive strategies for secondary prevention.¹⁵ Historically, cardiac stress testing was the cornerstone of risk stratification, but current guidelines and campaigns now discourage frequent or routine follow-up testing. While PROs are validated measures of symptoms, function, and quality of life, their utility in updating risk stratification in routine practice has not been well established. In this secondary analysis from the ISCHEMIA trial, we identified clinically significant associations between the SAQ and subsequent major adverse cardiovascular events. In both conservatively managed and recently revascularized cohorts, each 5-point increment in SAQ-SS was associated with 7–9% reduction in clinical events over a 3-year follow-up. When evaluating which SAQ assessment was most informative during serial monitoring, the current score demonstrated the strongest association with prognosis, independent of other patient characteristics. These findings suggest that clinicians should prioritize a patient’s current health status when assessing prognosis and guiding management.

These results build on decades of research regarding the prognostic significance of health status. While the Canadian Cardiovascular Society classification and dyspnea symptoms have long been recognized as prognostically important, the inherent variability in clinician-led assessments has led to increased valuation of standardized information collected directly from patients.^{16, 17, 18} In CCD, prior studies have established the significance of cross-sectional SAQ scores.^{8, 9, 13} This study not only confirms these associations in a contemporary cohort but also provides novel insights into the relative importance of longitudinal assessments. We observed a pattern similar to that seen in heart failure, where current Kansas City Cardiomyopathy Questionnaire scores were associated with a 7–10% decreased risk of death or hospitalization per 5-point increase.¹⁹ This consistency supports the concept that PROs serve a dual purpose: quantifying symptom burden and dynamically risk-stratifying clinical prognosis.

Implications for Patient-centered Care & Population Health

The primary benefit of serial PRO assessment is to obtain valid, reliable, and sensitive measures of patient symptoms, physical function, and quality of life. The discovery that these assessments concurrently provide updated risk evaluations underscores their utility in identifying candidates for more intensive secondary prevention or revascularization. Furthermore, translating these scores into risk estimates can support shared decision-making, helping patients understand how their health status relates to future clinical risks.

Beyond the clinic, these findings have implications for population health and telehealth frameworks. Because lower SAQ-SS identify high-risk individuals, they can serve as a warning sign to prioritize patients for in-person follow up. Conversely, stable patients with high SAQ scores may require less frequent interventions, potentially unburdening clinics and preserving healthcare resources. Systemic SAQ use enables treatment strategies to be tailored to both the current symptom burden and the dynamic clinical risk of the individual patient.

Future Direction

The routine integration of PROs into clinical practice is increasingly endorsed by global bodies, such as the International Consortium for Health Outcomes Measurement.²⁰ Notably, the Centers for Medicare & Medicaid Services have already tied PRO assessments to reimbursement in a mandatory Ambulatory Specialty Model for heart failure.²¹ While current CCD guidelines assign the systematic use of PROs a class 2B–NR recommendation—reflecting the absence of clinical trials demonstrating improved outcomes—¹⁵ PROs remain more consistent over time and across providers than physician-assigned estimates like the New York Heart Association or the Canadian Cardiovascular Society classifications.^{6, 22, 23} Developing implementation strategies to support the routine collection and interpretation of PROs is therefore a research priority. Overcoming systemic barriers—including clinical time constraints and the need for seamless electronic health record integration—by leveraging digital health platforms will be essential to transitioning the SAQ from a research tool to a core component of high-quality CCD care. Successes in heart failure management, where standardized workflows and digital platforms have enabled efficient PRO capture, provide a scalable roadmap for integrating the SAQ into routine cardiovascular practice.²⁴

Limitations

These findings should be interpreted within the context of several limitations. Since ISCHEMIA participants had stable CCD with at least moderate ischemia, these results may not generalize to patients with recent acute coronary syndromes, left main disease, or milder ischemia. Additionally, event rates occurred in a trial environment characterized by aggressive, trial-mandated efforts to optimize the completeness of revascularization in the invasive arm and intense secondary prevention in all patients. Thus, while hazard ratios are likely consistent, absolute event rates may differ in real-world practice. Finally, the potential for unmeasured confounding remains; however, the consistency of these findings with prior reports in different populations is reassuring.

Conclusion

This analysis of the ISCHEMIA trial demonstrates that the SAQ-SS serves as a dynamic, patient-centered tool for updating the prognosis of patients with CCD. The most recent SAQ-SS is the strongest independent predictor of subsequent clinical events, superior to both prior scores and interval changes in health status. These findings expand the utility of the SAQ-SS beyond simple symptom quantification and support its integration into routine outpatient care to identify high-risk patients and guide individualized, evidence-based management.

Supplementary Material

Table S1

Figures S1–2

Appendices S1–2

What Is Known

• In patients with chronic coronary disease (CCD), the Seattle Angina Questionnaire Summary Score (SAQ-SS) is a validated measure of symptoms, physical function, and quality of life that is associated with long-term outcomes.

• While health status is subject to change, it remains undefined which specific metric—prior scores, current score, or the change over time—physicians should prioritize for risk stratification when serial assessments are available.

What This Study Adds

• Although prior, current, and change in SAQ-SS are each independently associated with future cardiovascular events, the most recent score (i.e., current score) is the strongest predictor of prognosis for both medically and invasively managed patients.

• Integrating serial SAQ-SS assessments into routine outpatient care provides a simple, patient-centered method for dynamically updating a patient’s prognosis and may help clinicians better tailor treatment strategies in CCD.

Abbreviations

BMI

Body mass index

CABG

Coronary artery bypass graft

CCD

Chronic coronary disease

CI

Confidence interval

eGFR

Estimated glomerular filtration rate

HR

Hazard ratio

ISCHEMIA

International Study of Comparative Health Effectiveness with Medical and Invasive Approaches

MI

Myocardial infarction

PCI

Percutaneous coronary intervention

PROs

Patient-reported outcomes

PAD

Peripheral vascular disease

QOL

Quality of life

SAQ

Seattle Angina Questionnaire

SAQ-SS

Seattle Angina Questionnaire Summary Score

Appendix I: ISCHEMIA Research Group

Kreton Mavromatis

Jason Linefsky

Todd Miller

Subhash Banerjee

Jonathan D. Newman

Robert M. Donnino

Muhamed Saric

Khaled Abdul-Nour

Peter H. Stone

James J. Jang

Gennie Yee

Steven Weitz

Suzanne Arnold

James Henry O’Keefe, Jr

Michael D. Shapiro

Steven A. Fein

Mikhail T. Torosoff

Radmila Lyubarova

Sulagna Mookherjee

Krzysztof Drzymalski

Edward O. McFalls

Santiago A. Garcia

Stefan C. Bertog

Rizwan A. Siddiqui

Areef Ishani

Ronnell A. Hansen

Michel Georges Khouri

Jonathan L. Goldberg

Richard Goldweit

Ronny A. Cohen

Brooks Mirrer

Victor Navarro

David E. Winchester

Marvin Kronenberg

Christopher McFarren

John F. Heitner

Ira M. Dauber

Charles Cannan

Sriram Sudarshan

Puja K. Mehta

Michael McDaniel

Stamatios Lerakis

Arshed Quyyumi

Nanette K. Wenger

Chester M. Hedgepeth

Heather Hurlburt

Alan Rosen

Zakir Sahul

Steve Leung

Hassan Reda

Khaled Ziada

Sampoornima Setty

Rajat S. Barua

Fadi Hage

James E. Davies

Massoud Leesar

Jaekyeong Heo

Amy Iskandrian

Firas Al Solaiman

Satinder Singh

Khaled Dajani

Mohammad El-Hajjar

Paul Der Mesropian

Joseph Sacco

Brian McCandless

Marisa Orgera

Mandeep S. Sidhu

Imran Arif

Hanan Kerr

Jorge F. Trejo (Gutierrez)

Gerald Fletcher

Gary E. Lane

Lynn M. Neeson

Pragnesh P. Parikh

Peter M. Pollak

Brian P. Shapiro

Kevin Landolfo

Anthony Gemignani

Daniel O’Rourke

Judith L. Meadows

Jason T. Call

Joseph Hannan

Robert Bojar

Deepti Kumar

John Mukai

Edward T. Martin

Gabriel Vorobiof

Alec Moorman

Scott Kinlay

Robert J. Hamburger

Thomas P. Rocco

Deepak L. Bhatt

Kevin Croce

Jacquelyn A Quin

Jati Anumpa

Marco Zenati

David P Faxon

Glenn Rayos

Ashraf Seedhom

Lance Sullenberger

Gregory Kumkumian

Steven P. Sedlis

Robert M. Donnino

Jeffrey Lorin

Jacqueline E. Tamis-Holland

Robert Kornberg

Robert Leber

Souheil Saba

Michael W. Lee

Delano R. Small

Wassim Nona

Patrick B. Alexander

Iram Rehman

Umesh Badami

Kevin Marzo

Inga H. Robbins

Howard A. Levite

Sanjay Shetty

Mayuri Patel

Glenn S. Hamroff

Raymond W. Little

Brandi D. Zimbelman

Charles Y. Lui

Brigham R. Smith

Daniel P. Vezina

Lillian L. Khor

Josephine D. Abraham

David A. Bull

Stephen H. McKellar

David Booth

John Kotter

Ahmed Abdel-Latif

Bob Hu

Arthur J. Labovitz

Michael Berlowitz

Philip Rogal

Fadi Matar

Christiano Caldeira

Fatima Rodriguez

Ingela Schnittger

William F. Fearon

Prakash Deedwania

Kiran Reddy

Joseph Sweeny

Christopher Spizzieri

Claudia P Hochberg

William D. Salerno

Ray Wyman

Amer Zarka

Anil V. Shah

Thomas Haldis

Jeffrey A. Kohn

Saket Girotra

Omar Almousalli

Mayil S. Krishnam

Jeffrey C. Milliken

Pranav M. Patel

Arnold H. Seto

Kevin T. Harley

Michael A. Gibson

Byron J. Allen

Rita Coram

Sabu Thomas

Ronald G Schwartz

Wei Chen

Mahfouz El Shahawy

James Stafford

William B. Abernethy

Andrew Zurick

Thomas M. Meyer

Ronald G. Morford

Bruce Rutkin

Sabahat Bokhari

Seth I. Sokol

Jay Meisner

Ihab Hamzeh

Arunima Misra

Matthew Wall Jr.

Veronica Lenges De Rosen

Mahboob Alam

Michael C. Turner

Thomas J. Mulhearn

Arnold P. Good

Nicolas W. Shammas

Robert Chilton

Patricia K. Nguyen

Matthew Jezior

Paul C. Gordon

Thomas Crain

Robert Stenberg

Ronald P. Pedalino

Joseph Wiesel

George J. Juang

Mohammed Al-Amoodi

David Wohns

Ellis W. Lader

Michael Mumma

Lekshmi Dharmarajan

Joseph F.X. McGarvey Jr

Thomas R. Downes

Gary J. Luckasen

Benjamin Cheong

Srinivasa Potluri

Ronald A. Mastouri

Jeffery A. Breall

George E. Revtyak

Jonathan W. Bazeley

Dayuan Li

Kenneth Giedd

Wayne Old

Francis Burt

Kozhaya Sokhon

Deepika Gopal

Uma S. Valeti

Jon Kobashigawa

Sajeev Chakanalil Govindan

Rajesh Gopalan Nair

Cholenahally Nanjappa Manjunath

Nagaraja Moorthy

Satvic Cholenahally Manjunath

Suryaprakash Narayanappa

Neeraj Pandit

Ranjit Kumar Nath

S.K. Dwivedi

V.S. Narain

Sharad Chandra

Gurpreet S. Wander

Rohit Tandon

Sarju Ralhan

Naved Aslam

Abhishek Goyal

G.Karthikeyan

S.Ramakrishnan

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Rakesh Yadav

Sandeep Singh

Ambuj Roy

Neeraj Parakh

Sunil Kumar Verma

Rajiv Narang

Sundeep Mishra

Nitish Naik

Gautam Sharma

Shiv Kumar Choudhary

Chetan Patel

Gurpreet Gulati

Sanjeev Sharma

V K Bahl

Anoop Mathew

Eapen Punnoose

Siddharth Gadage

Tapan Umesh Pillay

Santhosh Satheesh

Atul Mathur

Johann Christopher

Rajeev Menon

Nirmal Kumar

Abraham Oomman

Robert Mao

Hilda Solomon

Sajeeda Parveen Khan

Purvez Grant

Ranjan Kachru

Ajit Kumar VK

Sanjay Ganapathi

Jayakumar K

Harikrishnan Sivadasanpillai

Bijulal Sasidharan

Kapilamoorthy TR

Praneeth Polamuri

Upendra Kaul

Keith AA Fox

Kathryn Carruthers

Ahmed Elghamaz

Sothinathan Gurunathan

Nikolaos Karogiannis

Benoy N Shah

Richard HJ Trimlett

Michael B Rubens

Edward D Nicol

Tarun K Mittal

Reinette Hampson

Reto Andreas Gamma

Mark A de Belder

Jeet Thambyrajah

Thuraia Nageh

John R Davies

Steven J. Lindsay

John Kurian

Haqeel Jamil

Osama Raheem

Angela Hoye

Patrick Donnelly

Bernardas Valecka

Anoop Chauhan

Craig Barr

Khaled Alfakih

Jonathan Byrne

Ian Webb

Peter Henriksen

Peter OKane

Ramesh de Silva

Dwayne S. G. Conway

Alexander A Sirker

Stephen P Hoole

Fraser N. Witherow

Nicola Johnston

Mark Harbinson

Simon Walsh

Hanna Douglas

Matthew Luckie

Jolanta Sobolewska

Paramjit Jeetley

Niket Patel

Tushar Kotecha

Christopher Travill

Iqbal Karimullah

Mahmud Al-Bustami

Denise Braganza

Robert Henderson

Kate Pointon

Surendra Naik

Thomas Mathew

Colin Berry

Damien Collison

Giles Roditi

Andrew J Moriarty

Jason D. Glover

Jiwan Pradhan

Mikhail Ghada

Darrel P. Francis

Vladimir Dzavik

Ariel Diaz

Philippe Rheault

Miguel Barrero

Carl-Éric Gagné

Yanek Pépin-Dubois

Ricardo Costa

Ying Tung Sia

Catherine Lemay

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Pierre Gervais

Alain Rheault

Denis Carl Phaneuf

Gilbert Gosselin

Pallav Garg

Renee C. Hessian

Rob S. Beanlands

Richard F. Davies

Asim N. Cheema

Akshay Bagai

Ron Wald

Shaun Goodman

John Joseph Graham

Mark Peterson

Chi-Ming Chow

Beth Abramson

Asim Nazir Cheema

Mohammad Tariq Vakani

James Cha

Andrew G Howarth

Graham Wong

Amar Uxa

Paul Galiwango

Saleem Kassam

Ashok Mukherjee

A. Joseph Ricci

Andy Lam

Shamir Mehta

Jacob Udell

Philippe Généreux

Adnan Hameed

Ledjalem Daba

Whady Hueb

Paulo Cury Rezende

Alexandre Ciappina Hueb

Paola Emanuela Poggio Smanio

Alexandre Schaan de Quadros

Renato Abdala Karam Kalil

José Luiz da Costa Vieira

Gabriel Grossmann

Pedro Píccaro de Oliveira

Leonardo Bridi

Simone Savaris

João V Vitola

Rodrigo J Cerci

Fabio R Farias

Miguel M Fernandes

José Antonio Marin-Neto

André Schmidt

Moysés de Oliveira Lima Filho

Ricardo Mendes Oliveira

João Reynaldo Abbud Chierice

Carísi A. Polanczyk

Mariana V. Furtado

Luis F. Smidt

Antonio Carlos Carvalho

Gustavo Pucci

Flavio Lyra

Alvaro Rabelo Alves Junior

Marianna D. A. Dracoulakis

Rodolfo G. S. D Lima

Estevao Figueiredo

Paulo Ricardo Caramori

Rogerio Tumelero

Frederico Dall’Orto

Claudio T. Mesquita

Alexandre S. Colafranseschi

Amarino C. Oliveira Jr.

Luiz A. Carvalho

Isabella C. Palazzo

Andre S. Sousa

Expedito Eustáquio Ribeiro da Silva

Pedro Gabriel Melo de Barros e Silva

Luciana de Pádua Silva Baptista

Marcelo Jamus Rodrigues

Marcos Valério Coimbra de Resende

Jose Francisco Saraiva

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Witold Ruzyllo

Marcin Demkow

Radoslaw Pracon

Cezary Kepka

Anna Teresinska

Karolina Kryczka

Jan Henzel

Mateusz Solecki

Edyta Kaczmarska

Tomasz Mazurek

Jaroslaw Drozdz

Bartosz Czarniak

Malgorzata Frach (formerly Stasiak)

Konrad Szymczyk

Iwona Niedzwiecka

Sebastian Sobczak

Tomasz Ciurus

Piotr Jakubowski

Magdalena Misztal-Teodorczyk

Dawid Teodorczyk

Aleksandra Fratczak

Marcin Szkopiak

Patrycja Lebioda

Michal Wlodarczyk

Anna Plachcinska

Jacek Kusmierek

Magdalena Miller

Halina Marciniak

Karolina Wojtczak-Soska

Katarzyna Łuczak

Tomasz Tarchalski

Anna Cichocka-Radwan

Grazyna Anna Szulczyk

Adam Witkowski

Krzysztof Kukuła

Małgorzta Celińska-Spodar

Joanna Zalewska

Grzegorz Gajos

Krzysztof Bury

Piotr Pruszczyk

Marek Roik

Krystyna Łoboz-Grudzień

Leszek Sokalski

Barbara Brzezińska

Maciej Lesiak

Magdalena Łanocha

Krzysztof W. Reczuch

Zbigniew Kalarus

Andrzej Swiatkowski

Mariola Szulik

Wlodzimierz J. Musial

Leo Bockeria

Karen Petrosyan

Tatiana Trifonova

Alexander M. Chernyavskiy

Evgeniy I. Kretov

Igor O. Grazhdankin

Leonid L. Bershtein

Sergey A. Sayganov

Anastasia M. Kuzmina-Krutetskaya

Elizaveta V. Zbyshevskaya

Nana O. Katamadze

Elena A. Demchenko

Pavel S. Kozlov

Vikentiy Y. Kozulin

Ekaterina I. Lubinskaya

Jose Lopez-Sendon

Almudena Castro

Elena Refoyo Salicio

Gabriela Guzman

Gabriel Galeote

Silvia Valbuena

Jesús Peteiro

María Dolores Martínez-Ruíz

Ruth Pérez-Fernández

José J Cuenca-Castillo

Xacobe Flores-Ríos

Óscar Prada-Delgado

Gonzalo Barge-Caballero

Jose Ramon Gonzalez Juanatey

Miguel Souto Bayarri

Virginia Pubull Nuñez

Raymundo Ocaranza Sanchez

Belen Cid Alvarez

Carlos Peña Gil

Amparo Martinez Monzonis

Alessandro Sionis

Montserrat Vila Perales

Josep Maria Padró

Antonio Serra Peñaranda

Joan García Picart

Antonino Ginel Iglesias

Xavier Garcia-Moll Marimon

Guillem Pons Lladó

Francesc Carreras Costa

Vicente Miro

Jose L Diez

Pilar Calvillo

F. Marin Ortuño

M. Valdés Chávarri

A. Tello Montolliu

E. Pinar Bermudez

G. De La Morena

Montserrat Gracida Blancas

Jose Enrique Castillo Luena

Francisco Fernandez-Aviles

Jiyan Chen

Yongjian Wu

Yitong Ma

Yining Yang

Zheng Ji

Xinchun Yang

Wenhua Lin

Hesong Zeng

Xin Fu

Songtao Wang

Gong Cheng

Yulan Zhao

Xuehua Fang

Qiutang Zeng

Xi Su

Qingxian Li

Shao-ping Nie

Qin Yu

Jian’an Wang

Shuyang Zhang

Zhenyu Liu

Aldo P. Maggioni

Gian Piero Perna

Marco Marini

Gabriele Gabrielli

Stefano Provasoli

Edoardo Verna

Lorenzo Monti

Barbara Nardi

Antonio Di Chiara

Andrea Mortara

Marcello Galvani

Filippo Ottani

Marco Sicuro

Paolo Calabro

Tiziana Formisano

Giuseppe Tarantini

Umberto Cucchini

Anto Luigi Andres

Emanuela Racca

Carlo Briguori

Roberto Amati

William Vergoni

Aldo Russo

Raffaele Fanelli

Kian-Keong Poh

Ping Chai

Titus Lau

Joshua P. Loh

Edgar L. Tay

Kristine Teoh

Lynette L. Teo

Ching-Ching Ong

Raymond C. Wong

Poay-Huan Loh

Theodoros Kofidis

Wan Xian Chan

Koo Hui Chan

David Foo

Jason Loh Kwok Kong

Ching Min Er

Fahim Haider Jafary

Terrance Chua

Juergen Stumpf

Klaus Matschke

Gregor Simonis

Clemens T. Kadalie

Udo Sechtem

P. Christian Schulze

Bjoern Goebel

Karsten Lenk

Georg Nickenig

Herwig Schuchlenz

Stefan Weikl

Irene Marthe Lang

Kurt Huber

Gabriele, Jakl-Kotauschek

Matyas Keltai

Andras Vertes

Albert Varga

Geza Fontos

Bela Merkely

Gabor Kerecsen

Sasa Hinic

Marija Zdravkovic

Vladan Mudrenovic

Bogdan Crnokrak

Branko D. Beleslin

Nikola N. Boskovic

Marija T. Petrovic

Milan R. Dobric

Zeljko Z. Markovic

Ana S. Mladenovic

Nada Cemerlic-Adjic

Goran Davidović

Rada Vučić

Milica Nikola Dekleva

Goran Stankovic

Svetlana Apostolovic

Jorge Escobedo

Rubén Baleón-Espinosa

Arturo S Campos-Santaolalla

Elihú Durán-Cortés

José M Flores-Palacios

Andrés García-Rincón

Moisés Jiménez-Santos

Joaquín V Peñafiel

José A Ortega-Ramírez

Aquiles Valdespino-Estrada

Erick Alexánderson Rosas

Deirdre Murphy

Joseph B. Selvanayagam

Majo X. Joseph

Suku T. Thambar

Jamie Rankin (past)

John F. Beltrame

Graham S. Hillis

Christophe Thuaire

Téodora Dutoiu

Jean-Michel Juliard

Michel S. Slama

Rami El Mahmoud

Eric Nicollet

Pascal Goube

Gilles Barone-Rochette

Alain Furber

Loïc Bière

Aleksandras Laucevicius

Elvin Kedhi MD

Jorik Timmer

Rik Hermanides

Eliza Kaplan

Robert K. Riezebos

Pouneh Samadi

Elise van Dongen

Sander R. Niehe

Harry Suryapranata

Stijn van Vugt

Duarte Cacela

Ana Santana

Antonio Fiarresga

Lidia Sousa

Hugo Marques

Lino Patricio

Luis Bernanrdes

Pedro Rio

Ramiro Carvalho

Rui Ferreira

Tiago Silva

Ines Rodrigues

Pedro Modas

Guilherme Portugal

Jose Fragata

Fausto J. Pinto

Miguel Nobre Menezes

Guilhermina Cantinho Lopes

Ana Gomes Almeida

Pedro Canas Silva

Angelo Nobre

Ana Rita Francisco

Nuno Ferreira

Ricardo L. Lopes

Rafael Diaz

Luis Guzman

Julio César Figal

Oscar Méndiz

Claudia Cortés

Roberto René Favaloro

Carlos Alvarez

Javier Courtis

Gabriela Zeballos

Lilia Schiavi

Mariano Rubio

Caroline Alsweiler

Gerard Patrick Devlin

Raewyn Fisher

Ralph Alan Huston Stewart

Harvey Douglas White

Jocelyne Benatar

Sasko Kedev

Irena Peovska Mitevska

Elizabeta Srbinovska Kostovska

Hristo Pejkov

Claes Held

Kai Eggers

Gunnar Frostfelt

Nina Johnston

Maciej Olsowka

Axel Åkerblom

Inga Soveri

Johannes Aspberg

Rafael Beyar

Eugenia Nikolsky

Tali Sharir

Dan Elian

Arthur Kerner

Samia Massalha

Keiichi Fukuda

Shun Kohsaka

Satoshi Yasuda

Shigeyuki Nishimura

Frans Van de Werf

Kathleen Claes

Chung-Lieh Hung

Chun-Ho Yun

Charles Jia-Yin Hou

Jen-Yuan Kuo

Hung-I Yeh

Ta-Chuan Hung

Jiun-Yi Li

Chen-Yen Chien

Cheng-Ting Tsai

Chun-Chieh Liu

Fa-Chang Yu

Yueh-Hung Lin

Wei-Ren Lan

Chih-Hsuan Yen

Jui-Peng Tsai

Kuo-Tzu Sung

Mpiko Ntsekhe

Shaheen Pandie

Charle A Viljoen

Marianne De Andrade

Tiziano Moccetti

M.Grazia Rossi

Magdy Abdelhamid

Ahmed Adel

Ahmed Kamal

Hossam Mahrous

Sameh El Kaffas

Hussien El Fishawy

Calin Pop

Matei Claudia

Bogdan A. Popescu

Carmen Ginghina

Dan Deleanu

Vlad A. Iliescu

Mouaz H. Al-Mallah

Ahmed Aljzeeri

Hani Najm

Ali Alghamdi

Walter Enrique Mogrovejo Ramos

Srun Kuanprasert

Arintaya Prommintikul

Weerachai Nawarawong

Surin Woragidpoonpol

Thitipong Tepsuwan

Noppon Taksaudom

Chataroon Rimsukcharoenchai

Juntima Euathrongchit

Yutthaphan Wannasopha

Sukit Yamwong

Piyamitr Sritara

Suthara Aramcharoen

Krissada Meemuk

Ahmad Khairuddin

Hafidz Abd Hadi

Shaiful Azmi Yahaya

John Doan

Raven Lee

Risha Patel

So Yang Cho

Susan Milbrandt

Dawn Shelstad

Preeti Kamath

Ishita Tejani

Kirsten J. Quiles

Allison Schley

Heather Golden

Hermine Osseni

Charlene Wiyarand

Peter Douglass

Hayley Pomeroy

Alexandra Craft

Bethany Harvey

Olivia Anaya

Phoebe Goold

Steven Giovannone

Lori Pritchard

Rosann Gans

Paul Kennedy

Shobana Ganesan

David Schlichting

Aynun Naher

Wendy L. Stewart

Kristin M. Salmi

Debra K. Johnson

Rebekah R. Herrmann

Kristine Arges

Melissa LeFevre

Jennifer Tomfohr

Kimberly Ann Byrne

Taissa Zappernick

Sallie Canada

Meghana Kakade

Patricia Mieses

Stanley E. Cobos

Raven R. Dwyer

Dalisa Espinosa

Kirsten J. Quiles

Magdalena Rantinella

Jessica Rodriguez

Olivia Mancilla

Susan Stinson

Terry Weyand

Sherron C. Crook

Jean Ho

Saadat Khan

Mahmoud Mohamed

Mary R. Soltau

Delsa K. Rose

Rebecca J. Wimmer

Kathy E. Siegel

Susan Derbyshire

Michelle Dixon

Gerald Leonard

Ciarra Heard

Viviana Gabriel

Sukie Desire

Fauzia Rashid

Senait Asier

Keyur Patel

Jennifer Gillis

Megan Manocchia

Susan Moore

Elizabeth Congdon

Gail Brandt

Nora Marchelletta

Kristina Wippler

Kimberly E. Halverson

Christine Roraff

Jonean Thorsen

Amarachi Ojajuni

Oni Olurinde

Kamalakar Surineni

Badhma Valaiyapathi

Carol M. Kartje

Michele Rawlins

Jennifer Thomson

Mary Colleen Rogge

Julie Bunke

Kendra Unterbrink

Jacqueline Fannon

Cynthia Burman

Marcia F. Dubin

Sarah Beaudry

Stephanie A. Tirado

Janet Halliday

Pamela Julian

Stephanie, M. Lane

Jennifer L. Stanford

Patricia Arsenault

Pamela Sigel

Miriam Brooks

Ladda Douangvila

Rubine Gevorgyan

Fatima Ranjbaran

Bryn Smith

Carly Ohmart

Samantha Ly

Margot C. Quinn

Sara Temiyasathit

Jacquelyn Do

Desiree Tobin

Jennifer Langdon

Marcia Werner Bayer

Amanda O’Malley

Erin Orvis

Mandy Murphy

Ann Greenberg

Margaret Iraola

Leandro C. Maranan

Ammy Malinay

Candice P. Edillo

Ann Ostrander

Stephanie Wasmiller

Wendy Drewes

Dipti Patel

Jackie M White

Alison Hallam

Benjamin J Spooner

Linda M Hollenweger

Holly Little

Tiffany Little

Nona A Eskelson

Yvonne Taul

Caroline Rodgers

Jennifer Isaacs

Viktoria Bulkley

Renee Kaneshiro

Bonnie J. Kirby

Nhi N. Tran

Catherine Jahrsdorfer

Reem Yunis

Jhina Patro

Antonia Vega

Hugo Bloise-Adames

Santa Jimenez

Nicole Saint Vrestil

Reyna Bhandari

Danielle Schade

Roxanne Yost

Paula Beardsley

Denise Fine

Jana Tancredi

Patricia Arakelian

Susan Mathus

Deborah O’Neill

Joy Burkhardt

Suellen Hosino

Oksana A. Lubyanaya

Jose D. Salas

Maria Aguirre

Manu Dhawan

Diana Parra

Tri Tran

Katie Fowler-Lehman

Natalie Spitzer

Casey Riedberger

Catherine Weick

Kirsten J. Quiles

Carrie Drum

Kimberly Miller-Cox

Amy Ollinger

Elizabeth Capasso-Gulve

Alaine Melanie Loehr

Marlowe Mosley

Shirin Heydari

Andrea M. Lundeen

Edgar Karanjah

Wanda C. Marfori

Eduardo Hernandez-Rangel

Pam Singh

Anne Marie Webb

Ellie Fridell

Heidi Wilson

Angela Kim

Patrick Wilmot

Ramona Stevens

Loriane Black

Amber B. Hull

Olivia J. Lim

Helen C. Tucker

Natasha C. Putnam

Linda L. Hall

Tia Cauthren

Trish Tucker

Hollie Horton

Jan Orga

Joyce R. White

Cynthia Baumann

Vidya Seeratan

Magnolia Jimenez

Cidney Schultz

Jeanne Russo

Zohra Huda

Araceli Boan

Christine R Hinton

Beth A. Archer

Julia S. Dionne

Cheryl A. Allardyce

Lindsey N. Sikora

Jennifer H. Czerniak

Jennifer A. Mull

Elizabeth Ferguson

Frances Laube

Gail A Shammas

Lori Christensen

Holly Park

Joan Hecht

Davis Vo

James Hirsch

Jody Bindeman

Sara Salkind

Lori-Ann Desimone

Lina Felix-Stern

Jassira Gomes

Catherine Gordon

Aimee Mann

Theresa McCreary

Kirsten J. Quiles

Candace Gopaul

Karen Hultberg

Tauqir Huk

Afshan Hussain

Yesenia Zambrano

Sarah Medina Rodriguez

Trudie Milner

Abbey Mulder

Stacie Van Oosterhout

Martha Meyer

Nancy L. Clapp

Heather Barrentine

Jenne M. Jose

Jenne Manchery

Vera McKinney

Linda Schwarz

Scott M. Kaczkowski

Adam J. Jaskowiak

Joel Klitch

Debra Dees

Precilia Vasquez

Elise L. Hannemann

Judy Mae Foltz

Emily DeRosa

Beth Jorgenson

Joyce Riestenberg-Smith

Rebecca Bariciano

Jessica Waldron

Michelle Mayon

Gretchen Ann Peichel

Brandy Starks

Lucilla Garcia

Maria Thottam

Anjali Anand

Janitha Raj

Reshma Ravindran

VS Rajalekshmi

Nandita Nataraj

Sheromani Bajaj

Vandana Yadav

Girish Mishra

Roma Tewari

Meenakshi Mishra

Shivali Patel

Suman Singh

Baljeet Kaur

Sonika Gupta

Chandini Suvarna

Binoy Mannekkattukudy Kurian

Sheetal Rupesh Karwa

Suvarna Kolhe

R. J. Vindhya

Peeyush Jain

Ashok Seth

Zile Singh Meharwal

Atul Verma

Mona Bhatia

Ankush Sachdeva

Thounaojam Indira Devi

Nungshi Jungla

K. Manjula Rani

M. Sowjanya Reddy

K. Preethi

Rinu R Sidh

Vamshi Priya

Kotiboinna Preethi

Shweta Hande

Abhishek Dubey

Kavita Rawat

Vineeth CP

Manas Chacko

Suresh Babu

Sowjanya Reddy

Manjula Rani

Priyadarshani Arambam

Bebek Singh

Grace M. Young

Christopher Kinsey

Raisa Kavalakkat

Jo Evans

Ikraam Hassan

Sarah Williams

Kim Holland

Karen Swan

Bev Atkinson

Swapna Kunhunny

Craig Atkinson

Carita Krannila

Manitha Vinod

Lisa Chaytor

Leanne Cox

Julie Morrow

Kay Rowe

Stephanie Kelly

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Dawn Turnbull

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Arijit Ghosh

Karen Gratrix

Stephen Preston

Anne Cartwright

Abigail Knightonc

Katherine Martin

Laura Flint

James Harrison

Nicki Lakeman

Anja Ljubez

Judith Wright

Donna Exley

Mervyn Andiapen

Amy J. Richards

Lisa Wong

Melanie J. Munro

Michelle McEvoy

Caroline Brown

Thabitha Charles

Laurel Kolakaluri

Hannah Phillips

Louise Morby

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Carolyn Corbett

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Angelique Smit

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Lisa McCloy

Kate Robb

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Wenda Crawford

Joanne Kelly

Lorraine McGregor

Anne Mackin

Janet P Knight

Tuhina Bose

Anna Proietti

Myriam Brousseau

Magalie Corfias

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Luc Harvey

Patricia Alarie

Linda Arcand

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Estelle Montpetit

Katia Drouin

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Christine Masson

Sandy Carr

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Ermina Moga

Janetta Kourzenkova

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Norma Hogg

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Olugbenga Bello

Ishba Syed

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Rebecca Otis

Michelle M Seib

Sandra M Rivest

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Suzana Tavares

Bev Bozek

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Sharon Tai

Sonya Brons

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Krystal Etherington

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Leonardo Pizzol Caetano

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Alice Manica Muller

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Sílvia Zottis Poletti

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Guilherme G Rucatti

Fernanda Igansi

Mauren P Haeffner

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Mayana Almeida

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Natalia S Oliveira

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Alexandre Tognon

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Olga Zdończyk

Joanna Jaroch

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Nodira Aripova

Ivan A. Naryshkin

Alena Kuleshova

Dastan Malaev

Irina Subbotina

Victoria Gumerova

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Moisés Blanco-Calvo

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Paula García-González

Jose Seijas Amigo

Ana Fernández Martínez

Begoña Igual

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JM. Rivera Caravaca

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Olga Sobrino

Alexandra Vazquez

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Peiyu He

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Junqing Yang

Qi Zhong

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Dongze Li

Xiaomei Li

Xiang Ma

Zixiang Yu

Qian Zhao

Chunguang Li

Lei Zhang

Yu Zhao

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Mulei Chen

Hongjie Chi

Yang Wang

Jing Zhang

Rui Jing

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Qiang Zhou

Chang Xu

Zhuxi Li

Junhua Li

Luyang Xiong

Dan Gao

Dengke Jiang

Ran Leng

Xutong Wang

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Lili Zhang

Ziliang Bai

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Jie Qi

Fei Wang

Haitao Wang

Bin Yang

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Zhulin Zhang

Yumei Dong

Jiajia Mao

Bin Zhang

Xiuhong Li

Xiaowei Yao

Nier Zhong

Ning Zhou

Yaping Huang

Panpan Zhou

Wei Su

Yu Kunwu

Yudong Peng

Xin Su

Chen Wang

Yunhai Zhao

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Yanfu Wang

Jing-yao Fan

Si-ting Feng

Xiao Wang

Yan Yan

Hui-min Zhang

Lingping Chi

Fang Liu

Han Chen

Jun Jiang

Huajun Li

Yechen Han

Lihong Xu

Gang Chen

Rongrong Hu

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Anna Di Donato

Francesca Pezzetta

Valentina Casali

Chiara Attanasio

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Cristina Bare

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Cecilia Goletto

Francesca De Micco

Stefano Di Marco

Martina Tricoli

Massimo Villella

Sik-Yin V Tan

Winnie C Sia

Audrey W Leong

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Ina Wenzelburger

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Claudia, Wegmayrc

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Florian, Egger

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Ana D. Djordjevic-Dikic

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Jelena J. Stepanovic

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Ljiljana Pupic

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Gordana Stevanovic

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Dragana Stanojevic

Ramon de Jesús-Pérez

María Fernanda Canales Brassetti

Diego Adrián Vences Anaya

María Pérez García

Isabel Estela Carvajal Juarez

Magdalena Madero Rovalo

Sau Lee

Prince Thomas

Melissa D Chaplin

Jeanette K. Stansborough

Marilyn Black

Michelle M. Bonner

Kim F. Ireland

Clare Venn-Edmonds

Corine Thobois

Emilie Tachot

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Christel Vassaliere

Helene Abergel

Axelle Fuentes

Ludivine Eliahou

Olivier Dubourg

Pierre Michaud

Sarah Hadjih

Patricia Brito

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Jeremy Rautureau

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Ilona Tamasauskiene

Agne Urboniene

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Lia Nijmeijer

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Elisabeth, M. Janzen

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Philippe Menasche

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Michael Mack

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Ileana L. Pina

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Hicham Skali

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David Waters

Patricia Endsley

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Dana Oliver

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Jeffrey Blume

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David Cohen

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Jonathan Himmelfarb

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Laura Drew

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