cardiovascular-agents and Angina-Pectoris

Angina pectoris remains a significant burden despite advances in medical therapy and coronary revascularization. Many patients (up to 30%) with angina have normal coronary arteries, with coronary microvascular disease and/or coronary artery vasospasm being major drivers of the myocardial demand-supply mismatch. Even among patients revascularized for symptomatic epicardial coronary stenosis, recurrent angina remains highly prevalent. Medical therapy for angina currently centers around 2 disparate goals, viz secondary prevention of hard clinical outcomes and symptom control. Vasodilators, such as nitrates, have been first-line antianginal agents for decades, along with beta-blockers and calcium channel blockers. However, efficacy in symptoms control is heterogenous, depending on underlying mechanism(s) of angina in an individual patient, often necessitating multiple agents. Nicorandil (NCO) is an antianginal agent first discovered in the late 1970s with a uniquely dual mechanism of action. Like a typical nitrate, it mediates medium-large vessel vasodilation through nitric oxide. In addition, NCO has adenosine triphosphate (ATP)-dependent potassium channel agonist activity (K ATP ), mediating microvascular dilatation. Hence, it has proven effective in both coronary artery vasospasm and coronary microvascular disease, typically challenging patient populations. Moreover, emerging evidence suggests that cardiomyocyte protection against ischemia through ischemic preconditioning may be mediated through K ATP agonism. Finally, there is now fairly firm evidence in favor of NCO in terms of hard event reduction among patients with stable coronary artery disease, following myocardial infarction, and perhaps even among patients with congestive heart failure. This review aims to summarize the mechanism of action of NCO, its efficacy as an antianginal, and current evidence behind its impact on hard outcomes. Finally, we review other cardiac and emerging noncardiac indications for NCO use.

Topics: Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Coronary Vasospasm; Humans; Nicorandil; Nitrates; Vasodilator Agents

Topics: Angina Pectoris; Angina, Stable; Cardiovascular Agents; Clinical Trials as Topic; Computed Tomography Angiography; Disease Management; Echocardiography; Humans; Myocardial Revascularization; Percutaneous Coronary Intervention; Referral and Consultation

The placebo effect is a well described phenomenon in blinded studies evaluating antianginal therapeutics, although its effect on clinical research metrics remains unknown. We conducted a systematic review and meta-analysis to quantify the effect of placebo on end points of symptoms, life quality, and functional outcomes in randomized placebo-controlled trials (RCTs) of symptomatic stable coronary artery disease.. We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for double-blind RCTs of antiangina therapeutics. Patients randomized to the placebo arm were the study population. Main outcomes were the changes in exercise performance (exercise treadmill test [ETT] parameters), quality of life (Seattle Angina Questionnaire domains), symptoms (Canadian Cardiovascular Society angina class) and drug usage (nitroglycerin tablets per week) between baseline and after placebo treatment. The primary outcome was ETT total duration time. Data were pooled with a random effect model.. Seventy-eight RCTs (83% drug-controlled, 17% procedure-controlled) were included encompassing 4925 patients randomized to placebo. ETT total duration time was significantly improved after placebo treatment compared with baseline (mean, 29.2; 95% confidence interval, 20.6-37.8] seconds) with evidence of high heterogeneity (I. A substantial placebo effect was present in angina RCTs across a variety of functional and life quality metrics. High variability in placebo effect size was present, mostly unexplained by differences in study and patient characteristics.

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Placebo Effect; Quality of Life; Randomized Controlled Trials as Topic

Myocardial ischaemia results from coronary macrovascular or microvascular dysfunction compromising the supply of oxygen and nutrients to the myocardium. The underlying pathophysiological processes are manifold and encompass atherosclerosis of epicardial coronary arteries, vasospasm of large or small vessels and microvascular dysfunction - the clinical relevance of which is increasingly being appreciated. Myocardial ischaemia can have a broad spectrum of clinical manifestations, together denoted as chronic coronary syndromes. The most common antianginal medications relieve symptoms by eliciting coronary vasodilatation and modulating the determinants of myocardial oxygen consumption, that is, heart rate, myocardial wall stress and ventricular contractility. In addition, cardiac substrate metabolism can be altered to alleviate ischaemia by modulating the efficiency of myocardial oxygen use. Although a universal agreement exists on the prognostic importance of lifestyle interventions and event prevention with aspirin and statin therapy, the optimal antianginal treatment for patients with chronic coronary syndromes is less well defined. The 2019 guidelines of the ESC recommend a personalized approach, in which antianginal medications are tailored towards an individual patient's comorbidities and haemodynamic profile. Although no antianginal medication improves survival, their efficacy for reducing symptoms profoundly depends on the underlying mechanism of the angina. In this Review, we provide clinicians with a rationale for when to use which compound or combination of drugs on the basis of the pathophysiology of the angina and the mode of action of antianginal medications.

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Precision Medicine

To determine the impact of ivabradine on outcomes important to patients with angina pectoris caused by coronary artery disease.. We conducted a systematic review. We included randomised clinical trials comparing ivabradine versus placebo or no intervention for patients with angina pectoris due to coronary artery disease published prior to June 2020. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, Cochrane methodology, Trial Sequential Analysis, Grading of Recommendations Assessment, Development, and Evaluation, and our eight-step procedure. Primary outcomes were all-cause mortality, serious adverse events and quality of life.. We included 47 randomised clinical trials enrolling 35 797 participants. All trials and outcomes were at high risk of bias. Ivabradine compared with control did not have effects when assessing all-cause mortality (risk ratio [RR] 1.04; 95% CI 0.96 to 1.13), quality of life (standardised mean differences -0.05; 95% CI -0.11 to 0.01), cardiovascular mortality (RR 1.07; 95% CI 0.97 to 1.18) and myocardial infarction (RR 1.03; 95% CI 0.91 to 1.16). Ivabradine seemed to increase the risk of serious adverse events after removal of outliers (RR 1.07; 95% CI 1.03 to 1.11) as well as the following adverse events classified as serious: bradycardia, prolonged QT interval, photopsia, atrial fibrillation and hypertension. Ivabradine also increased the risk of non-serious adverse events (RR 1.13; 95% CI 1.11 to 1.16). Ivabradine might have a statistically significant effect when assessing angina frequency (mean difference (MD) 2.06; 95% CI 0.82 to 3.30) and stability (MD 1.48; 95% CI 0.07 to 2.89), but the effect sizes seemed minimal and possibly without any relevance to patients, and we identified several methodological limitations, questioning the validity of these results.. Our findings do not support that ivabradine offers significant benefits on patient important outcomes, but rather seems to increase the risk of serious adverse events such as atrial fibrillation and non-serious adverse events. Based on current evidence, guidelines need reassessment and the use of ivabradine for angina pectoris should be reconsidered.. CRD42018112082.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Female; Humans; Ivabradine; Male; Middle Aged; Patient Safety; Quality of Life; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Treatment Outcome

Chest pain in patients without obstructive coronary artery disease has been realized as a frequent problem encountered in clinical practice. Invasive flow investigations have suggested that up to two-thirds of patients with nonobstructive coronary atherosclerosis may have microvascular dysfunction (MVD). Positron emission tomography myocardial perfusion imaging in conjunction with tracer-kinetic modeling enables the concurrent quantification of myocardial blood flow (MBF) in milliliters per minute per gram of tissue. This allows the assessment of hyperemic MBFs and myocardial flow reserve for the noninvasive identification and characterization of MVD as an important functional substrate for angina symptoms amenable to intensified and individualized medical intervention with nitrates, calcium-channel blockers, statins, angiotensin-converting enzyme inhibitors, and/or angiotensin II type 1 receptor blockers. Recent investigations suggest that cardiac magnetic resonance and computed tomography may also be suitable for the noninvasive detection of MVD. Whether intensified and individualized treatment related improvement or even normalization of hyperemic MBF and/or myocardial flow reserve may lead to a persistent reduction in angina symptoms and/or improved cardiovascular outcome as compared to standard care, deserves further testing in large-scale randomized clinical trials.

Topics: Adult; Aged; Angina Pectoris; Blood Flow Velocity; Cardiovascular Agents; Coronary Artery Disease; Coronary Circulation; Female; Humans; Hyperemia; Magnetic Resonance Imaging; Male; Microcirculation; Middle Aged; Myocardial Perfusion Imaging; Positron Emission Tomography Computed Tomography; Predictive Value of Tests; Progression-Free Survival; Risk Factors; Risk Reduction Behavior

The goal of this study was to investigate the effects of the antianginal drugs ranolazine, nicorandil, and ivabradine on coronary microvascular function.. Electronic scientific databases were searched for randomized trials investigating the effects of antianginal drugs on coronary microvascular function. Primary outcomes were changes in the coronary flow reserve (CFR), index of microvascular resistance (IMR), and myocardial perfusion reserve index (MPRI). The secondary outcome was the Seattle Angina Questionnaire scores. The standardized mean difference or weighted mean difference (WMD) (95% CI) served as a summary statistic.. The antianginal drugs ranolazine, nicorandil, and ivabradine did not increase the CFR compared with the control drugs (standardized mean difference, 0.39; 95% CI, -0.08 to 0.85; P = 0.10). Ranolazine did not increase the global MPRI compared with the control drugs (weighted mean difference [WMD], 0.11; 95% CI, -0.06 to 0.29; P = 0.21). However, in the subgroups with a baseline CFR <2.5 or a global MPRI <2, ranolazine increased the global MPRI (WMD, 0.19; 95% CI, 0.10 to 0.27; P < 0.0001). In addition, the subendocardial midventricular MPRI (mid-subendocardial MPRI) was improved after ranolazine treatment (WMD, 0.12; 95% CI, 0.03 to 0.20; P = 0.007). Moreover, nicorandil significantly reduced the IMR compared with the control drugs (WMD, -7.63; 95% CI, -11.82 to -3.44; P = 0.0004). In addition, ranolazine and ivabradine improved 3 of the 5 Seattle Angina Questionnaire scores.. Ranolazine improved the global MPRI in patients with definite coronary microvascular dysfunction and the mid-subendocardial MPRI with suspicious coronary microvascular dysfunction, and nicorandil reduced the IMR. In addition, ranolazine and ivabradine reduced angina. Moreover, it is possible that the IMR and mid-subendocardial MPRI are more sensitive than the CFR and global MPRI for evaluating coronary microvascular function.

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Humans; Ivabradine; Myocardial Ischemia; Nicorandil; Randomized Controlled Trials as Topic; Ranolazine; Treatment Outcome

Chronic stable angina is the most prevalent symptom of ischaemic heart disease and its management is a priority. Current guidelines recommend pharmacological therapy with drugs classified as being first line (beta blockers, calcium channel blockers, short acting nitrates) or second line (long-acting nitrates, ivabradine, nicorandil, ranolazine, and trimetazidine). Second line drugs are indicated for patients who have contraindications to first line agents, do not tolerate them or remain symptomatic. Evidence that one drug is superior to another has been questioned. Between January and March 2018, we performed a systematic review of articles written in English over the past 50 years English-written articles in Medline and Embase following preferred reporting items and the Cochrane collaboration approach. We included double blind randomized studies comparing parallel groups on treatment of angina in patients with stable coronary artery disease, with a sample size of, at least, 100 patients (50 patients per group), with a minimum follow-up of 1 week and an outcome measured on exercise testing, duration of exercise being the preferred outcome. Thirteen studies fulfilled our criteria. Nine studies involved between 100 and 300 patients, (2818 in total) and a further four enrolled greater than 300 patients. Evidence of equivalence was demonstrated for the use of beta-blockers (atenolol), calcium antagonists (amlodipine, nifedipine), and channel inhibitor (ivabradine) in three of these studies. Taken all together, in none of the studies was there evidence that one drug was superior to another in the treatment of angina or to prolong total exercise duration. There is a paucity of data comparing the efficacy of anti-anginal agents. The little available evidence shows that no anti-anginal drug is superior to another and equivalence has been shown only for three classes of drugs. Guidelines draw conclusions not from evidence but from clinical beliefs.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Humans; Nitrates; Randomized Controlled Trials as Topic

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. The majority of cases reported in the literature involve a single vessel; multivessel and left main (LM) coronary artery involvement is rare. We present a case of triple vessel and LM SCAD in a postpartum patient and review the literature regarding percutaneous coronary intervention in the setting of SCAD.

Topics: Acute Coronary Syndrome; Adult; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Vessel Anomalies; Drug-Eluting Stents; Female; Humans; Percutaneous Coronary Intervention; Postpartum Period; Pregnancy; Treatment Outcome; Ultrasonography, Interventional; Vascular Diseases

In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for traditional first-choice drugs. Considering some drugs, but not others, to be first choice is, therefore, difficult. Moreover, double or triple therapy is often needed to control angina. Patients with angina can have several comorbidities, and symptoms can result from various underlying pathophysiologies. Some agents, in addition to having antianginal effects, have properties that could be useful depending on the comorbidities present and the mechanisms of angina, but the guidelines do not provide recommendations on the optimal combinations of drugs. In this Consensus Statement, we propose an individualized approach to angina treatment, which takes into consideration the patient, their comorbidities, and the underlying mechanism of disease.

Topics: Angina Pectoris; Cardiology; Cardiovascular Agents; Clinical Decision-Making; Comorbidity; Consensus; Humans; Patient Selection; Patient-Centered Care; Risk Assessment; Risk Factors; Treatment Outcome

Angina persists for many patients despite modern medical therapy and/or revascularization, and this is referred to as refractory angina. All patients with refractory angina must be treated with aggressive risk factor modification plus optimized medical management. β-Blockers and nitrates are usually first-line agents; however most patients require multiple medications for refractory symptom control. Novel agents, such as ranolazine and ivabradine, as well as non-pharmacologic therapies, such as enhanced external counterpulsation and cardiac rehabilitation, may provide relief or reduction of angina. Other standard treatments such as antiplatelet therapy, lipid reduction therapy, blood pressure control, diabetes control, smoking cessation, and wei1ght control should be part of the management of refractory angina as well.

Topics: Angina Pectoris; Cardiac Rehabilitation; Cardiovascular Agents; Counterpulsation; Healthy Lifestyle; Humans; Recovery of Function; Risk Factors; Risk Reduction Behavior; Smoking Cessation; Treatment Outcome; Weight Loss

Half of women and 1/3 of men with angina and ischemia on stress testing have ischemia with no obstructive coronary artery disease (INOCA). These patients have quality of life (QoL) impairment comparable with patients with obstructive coronary artery disease. Clinicians generally treat INOCA with traditional antianginal agents despite previous studies demonstrating variable response to these medications. We performed a systematic review to evaluate the efficacy and safety of available pharmacologic therapies for INOCA. We systematically searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and the World Health Organization International Clinical Trials Registry Platform in July 2017 for randomized controlled trials (RCTs) evaluating pharmacologic agents for INOCA. The primary outcome of interest was QoL. Secondary outcomes included subjective and objective efficacy measures and safety outcomes. We included 35 RCTs from 333 identified studies. Interventions that improved QoL with moderate-quality evidence included angiotensin-converting enzyme (ACE) inhibitor (±statin) and ranolazine. Low-to-very-low-quality evidence also suggests that ACE inhibitors, β blockers, calcium-channel blockers, nicorandil, ranolazine, and statins may decrease angina frequency and delay ischemia on stress testing. Other interventions, most notably nitrates, did not significantly improve any outcome. In conclusion, evidence for pharmacologic treatment of INOCA is generally poor, and higher-quality RCTs using a standardized definition of INOCA are needed. Moderate-quality evidence suggests that ACE inhibitors and ranolazine improve QoL. Other interventions had low-quality evidence or no evidence of efficacy.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Myocardial Ischemia; Nicorandil; Nitrates; Quality of Life; Ranolazine; Vasodilator Agents

Ivabradine is an original drug that has been approved in two indications (systolic heart failure and angina). The aim of this short review is to draw the attention of clinician prescribers to the evidence base of ivabradine. Three large randomized trials testing ivabradine versus placebo have been performed. The BEAUTIFUL and SIGNIFY trials were in fact negative in the treatment of angina while the SHIFT trial found a marginal benefit of ivabradine over placebo in the treatment of heart failure. These important results are put into perspective in order to improve the assessment of risk-cost/benefit balances when ivabradine is considered. Ideally, a further clinical trial investigating the use of ivabradine in heart failure should be carried out with optimal treatment of the patient population in order to identify the subgroup of patients who respond to ivabradine.

Topics: Angina Pectoris; Cardiovascular Agents; Heart Failure; Heart Rate; Humans; Ivabradine; Randomized Controlled Trials as Topic; Stroke Volume; Treatment Outcome

The crucial issues in optimal medical therapy to improve prognosis and reduce angina symptoms are secondary prevention, effective control of concomitant diseases, risk factors and medical treatment. In spite of successful percutaneous coronary interventions (PCI) and medical treatment with beta-blockers, ACE-inhibitors or angiotensin receptor blockers, statins and antiplatelet drugs, some patients are still symptomatic. In the era of PCI not sufficient attention is paid to other drugs reducing the incidence of angina episodes: calcium antagonists, long-acting nitrates, metabolic agents and novel antianginal drugs. Substantial part of secondary coronary interventions may be avoided if angina pectoris would be properly treated. In the light of the Courage and BARI trials' results, optimal medical therapy of angina pectoris remains important part of treatment.

Topics: Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Disease; Humans; Secondary Prevention

Topics: Angina Pectoris; Benzazepines; Bradycardia; Cardiovascular Agents; Heart Failure; Heart Rate; Humans; Ivabradine; Patient Safety; Recovery of Function; Risk Assessment; Risk Factors; Treatment Outcome; Ventricular Function, Left

Refractory angina (RFA) is an unfavourable condition that is characterized with persistent angina due to reversible myocardial ischemia in patients with coronary artery disease that remains uncontrollable despite an optimal combination of pharmacological agents and revascularization. Despite significant advances in revascularization techniques and agents used in pharmacological therapy, there is still a significant population suffering from RFA and the global prevalence is even increasing. Anti- anginal treatment and secondary risk-factor modification are the traditional approaches for this group of patients. Furthermore, now there is still a large number of alternative treatment options. In order to review traditional and alternative treatment strategies in patients with RFA, we searched Pubmed for articles in English using the search terms "pharmacological therapy, refractory angina", "alternative therapy, refractory angina" between inception to June 2016. We also went through separately for each alternative treatment modality on Pubmed. To identify further articles, we handsearched related citations in review articles and commentaries. We also included data from the European Society of Cardiology (2013), and the Canadian Society of Cardiology/ Canadian Pain Society (2012) guidelines. Data show that besides traditional pharmacological agents, such as nitrates, beta- blockers or calcium channel blockers, novel antiischemic drugs and if symptoms persist, several non- invasive and/ or invasive alternative strategies may be considered. Impact of some pharmacological agents, such as rho- kinase inhibitors, and novel alternative treatment modalities, such as coronary sinus reducers, stem cell therapy, gene and protein therapy, on outcomes are still under investigation.

Topics: Angina Pectoris; Cardiovascular Agents; Complementary Therapies; Medicine, Traditional; Myocardial Revascularization

The peak sodium current underlies excitability and conduction in heart muscle, but a late sodium current flowing after the peak contributes to maintaining and prolonging the action potential plateau, and also to intracellular sodium loading, which in turn increases intracellular calcium with consequent effects on arrhythmia and diastolic function. Late sodium current is pathologically increased in both genetic and acquired heart disease, making it an attractive target for therapy to treat arrhythmia, heart failure, and angina. This review provides an overview of the underlying bases for the clinical implications of late sodium current block.

Topics: Action Potentials; Angina Pectoris; Arrhythmias, Cardiac; Cardiovascular Agents; Electrophysiologic Techniques, Cardiac; Heart Failure; Humans; Sodium Channels

It is important to know how to treat hypertension in patients with coronary artery disease (CAD). The reason for the review was to update this treatment and to discuss the 2015 American Heart Association/American College of Cardiology/American Society of Hypertension 2015 guidelines of treatment of hypertension in patients with CAD.. Studies between 1968 and 2015 were reviewed on treatment of hypertension in patients with CAD using a Medline search, and studies between 1977 and 2015 were reported. Hypertension should be treated with beta blockers and ACE inhibitors or angiotensin receptor blockers (ARBs). Long-acting nitrates are effective antianginal and anti-ischemic drugs. Calcium-channel blockers (CCBs) may be added if angina persists despite beta blockers and long-acting nitrates. The 2015 guidelines recommend that the blood pressure should be < 140/90 mm Hg in patients aged ≤ 80 years and the systolic blood pressure < 150 mm Hg if they are ≥ 80 years.. Hypertension in patients with CAD should be treated with beta blockers and ACE inhibitors or ARBs. Long-acting nitrates are effective antianginal and anti-ischemic drugs. CCBs may be added if angina persists despite beta blockers and long-acting nitrates. The blood pressure should be < 140/90 mm Hg in patients aged < 80 years and the systolic blood pressure < 150 mm Hg if they are ≥ 80 years.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Disease; Drug Therapy, Combination; Humans; Hypertension; Mineralocorticoid Receptor Antagonists; Nitrates; Practice Guidelines as Topic; Risk Factors; United States

The effect of stem/progenitor cells on myocardial perfusion and clinical outcomes in patients with refractory angina remains unclear because studies published to date have been small phase I-II trials.. We performed a meta-analysis of randomized controlled trials to evaluate the effect of cell-based therapy in patients with refractory angina who were ineligible for coronary revascularization.. Several data sources were searched from inception to September 2015, which yielded 6 studies. The outcomes pooled were indices of angina (anginal episodes, Canadian Cardiovascular Society angina class, exercise tolerance, and antianginal medications), myocardial perfusion, and clinical end points. We combined the reported clinical outcomes (myocardial infarction, cardiac-related hospitalization, and mortality) into a composite end point (major adverse cardiac events). Mean difference (MD), standardized mean differences, or odds ratio were calculated to assess relevant outcomes. Our analysis shows an improvement in anginal episodes (MD, -7.81; 95% confidence interval [CI], -15.22 to -0.41), use of antianginal medications (standardized MD, -0.59; 95% CI, -1.03 to -0.14), Canadian Cardiovascular Society class (MD, -0.58; 95% CI, -1.00 to -0.16), exercise tolerance (standardized MD, 0.331; 95% CI, 0.08 to 0.55), and myocardial perfusion (standardized MD, -0.49; 95% CI, -0.76 to -0.21) and a decreased risk of major adverse cardiac events (odds ratio, 0.49; 95% CI, 0.25 to 0.98) and arrhythmias (odds ratio, 0.25; 95% CI, 0.06 to 0.98) in cell-treated patients when compared with patients on maximal medical therapy.. The present meta-analysis indicates that cell-based therapies are not only safe but also lead to an improvement in indices of angina, relevant clinical outcomes, and myocardial perfusion in patients with refractory angina. These encouraging results suggest that larger, phase III randomized controlled trials are in order to conclusively determine the effect of stem/progenitor cells in refractory angina.

Topics: Angina Pectoris; Cardiovascular Agents; Cell- and Tissue-Based Therapy; Exercise Tolerance; Humans; Percutaneous Coronary Intervention; Randomized Controlled Trials as Topic; Treatment Outcome

Refractory angina refers to a group of patients with stable coronary atherosclerotic disease and angina symptoms, unresponsive to traditional medical management, while considered to be suboptimal candidates for revascularization procedures. Up to 15% of angina patients are considered to have refractory angina and, taking into account the aging population and the improvements in the treatment of stable coronary artery disease, the incidence of this entity is expected to increase. This review describes traditional and novel pharmacotherapies for symptoms relief and for long-term management of refractory angina. Mechanisms of action and relevant clinical trials are discussed and current recommendations from major European and US cardiovascular societies are reported.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Disease; Fibrinolytic Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Nicorandil; Nitrates; Ranolazine

Approaches to the pharmacotherapy of angina pectoris have previously centred on the concept that a transient imbalance between myocardial oxygen "demand" and supply within the myocardium can best be addressed by reducing demand (for example, with β-adrenoceptor antagonist) or by increasing availability of blood (via coronary vasomotor reactivity adjustment or coronary revascularization). However, this principle is potentially challenged by the emergence of cases of angina unsuitable for such therapies (for example because of concomitant severe systolic heart failure) and by the recognition that impaired myocardial energetics may precipitate angina in the absence of fixed or variable coronary obstruction (for example in hypertrophic cardiomyopathy). The past 20 years have seen the re-emergence of a class of anti-anginal agents which act primarily by improving efficiency of myocardial oxygen utilization, and thus can correct impaired energetics, simultaneously treating angina and heart failure symptoms. We review the principles underlying the safe use of such agents, beginning with the prototype drug perhexiline maleate, which despite complex pharmacokinetics and potential hepato- or neuro-toxicity has emerged as an attractive management option in many "complicated" cases of angina pectoris.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Fatty Acids; Glucose; Humans; Mitochondria; Myocardium; Perhexiline

Treatment of angina pectoris associated with coronary microvascular dysfunction is challenging as the underlying mechanisms are often diverse and overlapping. Patients with type 1 coronary microvascular dysfunction (i.e. absence of epicardial coronary artery disease and myocardial disease) should receive strict control of their cardiovascular risk factors and thus receive statins and ACE-inhibitors in most cases. Antianginal medication consists of ß-blockers and/or calcium channel blockers. Second line drugs are ranolazine and nicorandil with limited evidence. Despite individually titrated combinations of these drugs up to 30 % of patients have refractory angina. Rho-kinase inhibitors and endothelin-receptor antagonists represent potential drugs that may prove useful in these patients in the future.

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Circulation; Coronary Vessels; Humans; Microvessels

Stable angina pectoris affects 2-4 % of the population in Western countries and entails an annual risk of death and nonfatal myocardial infarction of 1-2 % and 3 %, respectively. Heart rate (HR) is linearly related to myocardial oxygen consumption and coronary blood flow, both at rest and during stress. HR reduction is a key target for the prevention of ischemia/angina and is an important mechanism of action of drugs which are recommended as first line therapy for the treatment of angina in clinical guidelines. However, many patients are often unable to tolerate the doses of beta blocker or non-dihydropyridine calcium antagonists required to achieve the desired symptom control. The selective pacemaker current inhibitor ivabradine was developed as a drug for the management of patients with angina pectoris, through its ability to reduce HR specifically. The available data suggest that ivabradine is a well-tolerated and effective anti-anginal agent and it is recommended as a second-line agent for relief of angina in guidelines. However, recent clinical trials of ivabradine have failed to show prognostic benefit and have raised potential concerns about safety. This article will review the available evidence base for the current role of ivabradine in the management of patients with symptomatic angina pectoris in the context of stable coronary artery disease.

Topics: Angina Pectoris; Benzazepines; Cardiovascular Agents; Drug Interactions; Drug Therapy, Combination; Heart Rate; Humans; Ivabradine

Angina pectoris is a common presenting symptom of underlying coronary artery disease or reduced coronary flow reserve. Patients with angina have impaired quality of life; and need to be treated optimally with antianginal drugs to control symptoms and improve exercise performance. A wide range of antianginal medications are approved for the treatment of angina, and often more than one class of antianginal drugs are used to adequately control the symptoms. This expert opinion highlights the likely cardiac adverse effects of available antianginal drugs, and how to minimize these in individual patients and especially during combination treatment. Areas covered: All approved antianginal drugs, including the older and newly approved medications with different mechanism of action to the older drugs as well as some of the unapproved herbal medications. The safety profiles and potential cardiac side effects of these medications when used as monotherapy or as combination therapy are discussed and highlighted. Expert opinion: Because of the different cardiac safety profiles and possible side effects, we recommend selection of initial drug or adjustment of therapy based on the resting heart rate; blood pressure, hemodynamic status; and resting left ventricular function, concomitant medications and any associated comorbidities.

Topics: Angina Pectoris; Animals; Blood Pressure; Cardiovascular Agents; Cardiovascular Diseases; Drug Therapy, Combination; Heart Rate; Humans; Plant Preparations; Quality of Life; Ventricular Function, Left

Angina pectoris, or symptomatic myocardial ischaemia, reflects an impairment of coronary blood flow, and usually a deficiency of available myocardial energetics. Treatment options vary with the precise cause, which may vary with regards to the roles of increased myocardial oxygen demand versus reduced supply. Traditionally, organic nitrates, β-adrenoceptor antagonists, and non-dihydropyridine calcium antagonists were the only commonly used prophylactic anti-anginal agents. However, many patients failed to respond adequately to such therapy, and/or were unsuitable for their use. Areas covered: A number of 'new' agents have been shown to represent ancillary forms of prophylactic anti-anginal therapy and are particularly useful in patients who are relatively unsuitable for either percutaneous or surgical revascularisation. These include modulators of myocardial metabolic efficiency, such as perhexiline, trimetazidine and ranolazine, as well as high dose allopurinol, nicorandil and ivabradine. The advantages and disadvantages of these various agents are summarized. Expert opinion: 'Optimal' medical treatment of angina pectoris now includes use of agents primarily intended to reduce risk of infarction (e.g. statins, aspirin, ACE inhibitors). In patients whose angina persists despite the use of 'standard' anti-anginal therapy, and who are not ideal for invasive revascularization options, a number of emerging drugs offer prospects of symptomatic relief.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Drug Design; Humans; Myocardial Infarction; Myocardial Ischemia; Oxygen

Ischemic heart disease (IHD) is a major cause of death and disability among Western countries and angina pectoris is the most prevalent symptomatic manifestation. Strategies to improve management of chronic stable angina are a priority. Areas covered: A comprehensive review was conducted using the Medline and Cochrane databases as well as the clinical trial databases in the United States and Europe. Traditional therapies for angina will be discussed. This review particularly emphasizes investigational therapies for angina (including pharmacological agents, cell and gene based therapies, and herbal medications). Expert opinion: There has been renewed interest in older anti-angina agents (e.g., perhexiline, amiodarone, and phosphodiestrase-5 inhibitors). Other anti-inflammatory agents (e.g., allopurinol and febuxostat) are currently undergoing evaluation for angina therapy. Therapeutic angiogenesis continues to face some challenges. Future trials should evaluate the optimum patient population that would benefit from this form of therapy.

Topics: Angina Pectoris; Angina, Stable; Cardiovascular Agents; Cell- and Tissue-Based Therapy; Drugs, Investigational; Genetic Therapy; Humans; Myocardial Ischemia

Coronary heart disease (CHD) is one of the leading causes of death worldwide. Moreover, angina pectoris is one of the most important types of CHD. Therefore, prevention and effective treatment of angina pectoris is of utmost importance in both China and western countries. However, undesirable effects of antianginal therapy do influence treatment adherence to a certain extent. Therefore, it's not surprising that, complementary and alternative medicine (CAM), including Chinese medicine (CM), are widely welcomed among patients with CHD, hoping that it might complement western medicine. In our previous studies, blood stasis syndrome (BSS) (Xueyu Zheng) was the main syndrome (Zheng-hou) of angina pectoris. Currently, China Food and Drug Administration authoritatively recommended more than 200 Chinese patent medicines (CPMs) as complementary or adjunctive therapies for symptom management and enhancing quality of life along with mainstream care on angina pectoris management in mainland China. This paper reviewed 4 kinds of most frequently-used CPMs by promoting blood circulation and removing blood stasis in the treatment of angina pectoris. It aims to evaluate the current evidence of CPMs in combination therapy for angina pectoris. This review indicated that CPMs as adjunctive treatment to routine antianginal therapy play an active role in reducing the incidence of primary endpoint events, decreasing anginal attack rate, and improving electrocardiogram. Additionally, CPMs have been proven relatively safe. Further rigorously designed clinical trials should be conducted to confirm the results.

Topics: Angina Pectoris; Biomarkers; Blood Circulation; Blood Coagulation; Cardiovascular Agents; Drug Therapy, Combination; Drugs, Chinese Herbal; Humans; Medicine, Chinese Traditional; Treatment Outcome

Chronic angina represents a condition that impairs quality of life and is associated with decreased life expectancy in the industrialized countries. Current therapies that reduce angina frequency include old drugs such as nitrates, β -blockers and calcium antagonists. Several new investigational drugs are being tested for the treatment of chronic angina. This review will focus on ranolazine, a drug approved by the US Food and Drug Administration (FDA) in 2006 for patients with chronic angina who continue to be symptomatic despite optimized therapies. The main molecular mechanism underlying ranolazine-mediated beneficial effects has been identified as inhibition of the late Na+ current during the action potential, which potentially improves oxygen consumption, diastolic dysfunction and coronary blood flow. The aim of this review is to update the evidence for ranolazine treatment in chronic angina and discuss its therapeutic perspectives based on the most recent clinical and experimental studies.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Controlled Clinical Trials as Topic; Diastole; Humans; Ranolazine; Sodium Channel Blockers

The purpose of this systematic review is to assess the effectiveness of acupuncture for angina pectoris.. Eleven electronic databases were searched until January 2013. The study included randomized controlled trials that the effectiveness of acupuncture alone was compared to anti-angina medicines (in addition to conventional treatment) and the effectiveness of a combination of acupuncture plus anti-angina medicines was compared to anti-angina medicines alone. The trial selection, data extraction, quality assessment and data analytic procedures outlined in the 2011 Cochrane Handbook were involved.. The study included 25 randomized controlled trials (involving 2,058 patients) that met our inclusion criteria. The pooled results showed that the number of patients with ineffectiveness of angina relief was less in the combined acupuncture-anti-angina treatment group than in the anti-angina medicines alone group (RR 0.33, 95% CI 0.23-0.47, p < 0.00001, I2 = 0%). Similarly, compared to the anti-angina medicines alone group, fewer patients in the combined treatment group showed no ECG improvement (RR 0.50, 95% CI 0.40-0.62, p < 0.00001, I2 = 0%). However, no differences were observed between acupuncture treatment alone and anti-angina medicines alone for both outcome measures. Only four trials mentioned adverse effects. One trial found no significant difference between acupuncture and Chinese medicine, and three reported no adverse events. The quality of the trials was found to be low.. The findings showed very low evidence to support the use of acupuncture for improving angina symptoms and ECG of angina patients. However, the quality of the trials included in this study was low. Large and rigorously designed trials are needed to confirm the potential benefit and adverse events of acupuncture.

Topics: Acupuncture Therapy; Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Female; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic

There have been no systematic reviews, let alone meta-analyses, of randomized controlled trials (RCTs) comparing tongxinluo capsule (TXL) and beta-blockers in treating angina pectoris. This study aimed to evaluate the efficacy of TXL and beta-blockers in treating angina pectoris by a meta-analysis of eligible RCTs.. The RCTs comparing TXL with beta-blockers (including metoprolol) in treating angina pectoris were searched and retrieved from databases including PubMed, Chinese National Knowledge Infrastructure, and WanFang Data. Eligible RCTs were selected according to prespecified criteria. Meta-analysis was performed on the odds ratios (OR) of symptomatic and electrocardiographic (ECG) improvements after treatment. Subgroup analysis, sensitivity analysis, meta-regression, and publication biases analysis were conducted to evaluate the robustness of the results.. Seventy-three RCTs published between 2000 and 2014 with 7424 participants were eligible. Overall ORs comparing TXL with beta-blockers were 3.40 (95% confidence interval [CI], 2.97-3.89; p<0.0001) for symptomatic improvement and 2.63 (95% CI, 2.29-3.02; p<0.0001) for ECG improvement. Subgroup analysis and sensitivity analysis found no statistically significant dependence of overall ORs on specific study characteristics except efficacy criteria. Meta-regression found no significant except sample sizes for data on symptomatic improvement. Publication biases were statistically significant.. TXL seems to be more effective than beta-blockers in treating angina pectoris, on the basis of the eligible RCTs. Further RCTs are warranted to reduce publication bias and verify efficacy.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Cardiovascular Agents; Drugs, Chinese Herbal; Humans; Treatment Outcome

Chronic angina is a common manifestation of ischaemic heart disease. Medical treatments are the mainstay approach to reduce the occurrence of angina and improve patients' quality of life. This Series paper focuses on commonly used standard treatments (eg, nitrates, β blockers, and calcium-channel blockers), emerging anti-angina treatments (which are not available in all parts of the world), and experimental treatments. Although many emerging treatments are available, evidence is scarce about their ability to reduce angina and ischaemia.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Chronic Disease; Humans; Nitrates; Technology, Pharmaceutical

Human sexuality is an important aspect of health and quality of life. Many patients with ischemic heart disease - and their partners - are concerned that sexual activity could exacerbate their cardiac condition, possibly causing myocardial infarction or cardiac death. Patients with ischemic heart disease who wish to initiate or resume sexual activity should be evaluated with a thorough medical history and physical examination. Sexual activity is reasonable for individuals with no or mild angina and those who can exercise ≥ 3-5 METS without angina, excessive dyspnea, or ischemic ST segment changes. For the patient who is considered not be at low cardiovascular (CV) risk or in whom the CV risk is unknown, an exercise stress test is reasonable in order to determine his or her exercise capacity and to ascertain if symptoms or ischemia may occur. Regular exercise and cardiac rehabilitation can be effective in reducing the risk of CV complications associated with sexual activity for the patient with ischemic heart disease.

Topics: Angina Pectoris; Cardiovascular Agents; Death, Sudden, Cardiac; Exercise Test; Humans; Myocardial Infarction; Myocardial Ischemia; Phosphodiesterase 5 Inhibitors; Risk Assessment; Sexual Behavior

Angina pectoris is the consequence of an inequality between the demand and supply of blood to the heart. Angina manifests itself as chest pain or discomfort and is a common complaint of patients in the hospital and in the clinic. There are, in fact, roughly half a million new cases of angina per year. Chest pain, while having many etiologies, is generally considered to be most lethal when related to a cardiac cause. In this review, the authors outline the current medical and surgical therapies that are used in the management of angina. Highlights of the various clinical trials that have assisted in the investigation of these therapies are summarized also. Then, the authors provide a focused review of the novel therapy options for angina that are currently being explored. From new medical treatments to revised surgical techniques to the discovery of stem cell therapy, many innovative options are being investigated for the treatment of angina.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Chest Pain; Clinical Trials as Topic; Humans; Stem Cell Transplantation

Topics: Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Electrocardiography; Humans; Microvascular Angina; Myocardial Infarction

Topics: Algorithms; Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Drug Therapy, Combination; Humans; Prognosis

The RASCAL (Refractory Angina Spinal Cord stimulation and usuAL care) pilot study seeks to assess the feasibility of a definitive trial to assess if addition of spinal cord stimulation (SCS) to usual care is clinically superior and more cost-effective than usual care alone in patients with refractory angina.. This is an external pilot, patient-randomized controlled trial.The study will take place at three centers in the United Kingdom - South Tees Hospitals NHS Foundation Trust (The James Cook University Hospital), Dudley Group of Hospitals NHS Foundation Trust, and Basildon and Thurrock University Hospitals NHS Foundation Trust.The subjects will be 45 adults with refractory angina, that is, limiting angina despite optimal anti-angina therapy, Canadian Cardiovascular Society Functional Classification Class III and IV, angiographically documented coronary artery disease not suitable for revascularization, satisfactory multidisciplinary assessment and demonstrable ischemia on functional testing.The study will be stratified by center, age and Canadian Cardiovascular Society Functional Classification.Interventions will involve spinal cord stimulation plus usual care ('SCS group') or usual care alone ('UC group'). Usual care received by both groups will include consideration of an education session with a pain consultant, trial of a transcutaneous electrical neurostimulation, serial thoracic sympathectomy and oral/systemic analgesics.Expected outcomes will be recruitment and retention rates; reasons for agreeing/declining participation; variability in primary and secondary outcomes (to inform power calculations for a definitive trial); and completion rates of outcome measures. Trial patient-related outcomes include disease-specific and generic health-related quality of life, angina exercise capacity, intake of angina medications, frequency of angina attacks, complications and adverse events, and satisfaction.. The RASCAL pilot trial seeks to determine the feasibility and design of a definitive randomized controlled trial comparing the addition of spinal cord stimulation to usual care versus usual care alone for patients with refractory angina.Fifteen patients have been recruited since recruitment opened in October 2011. The trial was originally scheduled to end in April 2013 but due to slow recruitment may have to be extended to late 2013.. ISRCTN65254102.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Protocols; Cost-Benefit Analysis; Drug Resistance; England; Feasibility Studies; Health Care Costs; Humans; Patient Satisfaction; Pilot Projects; Research Design; Spinal Cord Stimulation; Time Factors; Treatment Outcome

Topics: Acetanilides; Adrenergic beta-Antagonists; Angina Pectoris; Atrial Fibrillation; Benzazepines; Calcium; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Disease; Electrocardiography; Endothelium, Vascular; Heart Failure, Diastolic; Humans; Hypercalcemia; Ivabradine; Myocardial Ischemia; Nitrates; Piperazines; Ranolazine; Sodium; Sodium Channels; Sodium-Calcium Exchanger

Management of chronic angina has evolved dramatically in the last few decades with several options for pharmacotherapy outlined in various evidence-based guidelines.. There is a growing list of drugs that are currently being investigated for treatment of chronic angina. These also include several herbal medications, which are now being scientifically evaluated as potential alternative or even adjunctive therapy for angina. Gene- and cell-based therapies have opened yet another avenue for management of chronic refractory angina in 'no-option' patients who are not candidates for either percutaneous or surgical revascularization and are on optimal medical therapy. An extensive review of literature using PUBMED, Cochrane database, clinical trial databases of the USA and European Union was done and summarized in this review. This review will attempt to discuss the traditional as well as novel therapeutic agents for angina.. Several pharmacological and non-pharmacological therapeutic options are now available for treatment and management of chronic refractory angina. Renewed interest in traditional therapies and cell- and gene-based modalities with targeted drug delivery systems will open the doors for personalized therapy for patients with chronic refractory angina.

Topics: Angina Pectoris; Angiogenesis Inducing Agents; Animals; Cardiovascular Agents; Cell- and Tissue-Based Therapy; Humans; Phytotherapy

Percutaneous coronary intervention (PCI) decreases ischemic complications of acute coronary syndromes. The benefits of PCI in stable ischemic heart disease (SIHD) depend on its effect on quality of life (QoL), including angina, physical activity, and emotional well-being. PCI decreases angina and the need for anti-anginal medications, and increases exercise capacity and QoL, compared with baseline status and compared with medical therapy without PCI. These benefits are greater when QOL is markedly impaired by severe angina before the procedure. When considering treatment options for symptomatic SIHD, physicians should consider and provide objective data regarding QoL effects for each treatment strategy. QoL outcomes should be considered in clinical trials, appropriate use criteria, practice guidelines, and reimbursement policies for PCI.

Topics: Angina Pectoris; Cardiovascular Agents; Consensus; Coronary Artery Bypass; Emotions; Exercise Tolerance; Health Status; Humans; Mental Health; Myocardial Ischemia; Patient Selection; Percutaneous Coronary Intervention; Quality of Life; Treatment Outcome

Stable angina represents the main symptom of established coronary artery disease. In addition atherosclerosis is the common pathological substrate of chronic stable angina as well as acute coronary syndromes. The aim of stable angina management is the symptomatic relief and the secondary prevention. Lifestyle modification and pharmacological therapy are the cornerstones of chronic coronary artery disease management irrespectively of possible surgical or percutaneous revascularization. Optimal medical therapy is a combination of antianginal/antiischemic drugs and disease modifying agents, including nitrates, beta-blockers, calcium channel blockers, antiplatelets, statins and angiotensin converting enzyme inhibitors. Novel classes of treatment with different mechanisms of action have been developed in the last years, including nicorandil, ivabradine, trimetazidine and ranolazine. These drugs, which are currently approved as second-line treatments, have dynamically entered the clinical practice and their long-term effects are still under investigation.

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Life Style

Refractory angina pectoris constitutes a manifestation of severe ischemic heart disease that cannot be treated adequately either with conventional medication or with interventional techniques including percutaneous coronary angioplasty (PTCA). As a result, new therapeutic strategies, aiming on angiogenesis, were evolved in order to improve functional class and health related quality of life (HRQOL) indices. Among them, gene therapy constitutes a very promising alternative treatment for these patients. In this review, we will describe i) the definition of refractory angina ii) pathophysiology of angiogenesis, iii) routine as well as novel imaging techniques of neovascularization and iv) current treatment options for refractory angina. Secondly we will review the main angiogenic clinical trials, which will also be commented regarding their effectiveness to reduce the recurrency of angina symptoms and improve health-related quality-of-life, as well as the functional class of patients with chronic ischemic disease.

Topics: Angina Pectoris; Cardiovascular Agents; Genetic Therapy; Humans; Magnetic Resonance Imaging; Neovascularization, Pathologic; Positron-Emission Tomography

In chronic stable angina of mild or moderate severity, there is an ongoing debate as to which treatment strategy should be offered to patients: intense medical drug therapy combined with revascularization if medical therapy fails, or direct coronary angiography in view of immediate revascularization in all patients if feasible, both combined with strict risk factor control and secondary prevention. Findings of two large randomized controlled trials, COURAGE and BARI 2D showed that in selected patients with mild to moderate angina and documented coronary disease by coronary angiography suitable for revascularization, there was no difference in death or myocardial infarction between the two strategies. It remains unclear, however, how these findings can be generalized to the broader spectrum of patients with unknown coronary anatomy. This review describes both treatment strategies, their strengths and limitations, and stresses the importance of the documentation of the extent of myocardial ischemia in risk stratifying such patients. Based on the available trial evidence, an algorithm is proposed how to tailor the management strategy to each patient's individual situation.

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Humans; Myocardial Infarction; Myocardial Revascularization; Patient Selection; Risk Assessment; Risk Factors; Treatment Outcome

Management of stable angina pectoris includes antianginal medications, medications to prevent progression of atherosclerosis, and aggressive treatment of causative risk factors. Antianginal medications commonly used include nitrates, beta-blockers, calcium channel blockers, and ranolazine. Antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors are used in patients with these problems to prevent progression of atherosclerosis and/or premature cardiovascular death. Aggressive risk factor control with diet; exercise; treatment of diabetes, hypertension, and dyslipidemia; and strategies to stop smoking and reduce weight should be a part of treatment strategy in all patients. Patients with stable angina who have symptoms refractory to medical treatment usually require coronary angiography, followed by either percutaneous or surgical revascularization. Recent mechanical techniques for the treatment of refractory angina include transmyocardial laser revascularization, enhanced external counterpulsation, and spinal cord stimulation.

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Electric Stimulation Therapy; Exercise; Humans; Myocardial Revascularization; Risk Factors; Smoking Cessation; Weight Loss

published data indicate that heart rate is an independent strong predictor of cardiovascular and all-cause mortality in men and women of all ages, with and without cardiovascular disease, including atherosclerosis, ventricular arrhythmias, and left ventricular dysfunction. Ivabradine is a pure heart-rate-lowering agent with well-documented antianginal and anti-ischemic properties comparable to well-established anti-anginal agents.. this short review explores recent results with ivabradine, a new medication that lowers heart rate by selectively inhibiting the I (f) current. This review also describes future potential applications.. measurement of heart rate represents an important component of the assessment of patients with coronary artery disease and chronic heart failure, and should be viewed in the same light as other risk factors, because a high heart rate has direct detrimental effects not only on myocardial ischemia but also on the progression of atherosclerosis, ventricular arrhythmias and left ventricular function. Ivabradine has anti-ischemic and antianginal efficacy equivalent to that of β-blockers and calcium channel antagonists in the treatment of chronic stable angina pectoris. Recently ivabradine has been shown to improve cardiac outcomes in stable coronary artery disease and left ventricular systolic dysfunction in patients who have heart rates of ≥ 70 bpm and in patients with stable angina.

Topics: Angina Pectoris; Animals; Benzazepines; Cardiovascular Agents; Cardiovascular Diseases; Coronary Artery Disease; Female; Heart Rate; Humans; Ivabradine; Male; Risk Factors; Ventricular Dysfunction, Left

The article is devoted to results of randomized clinical trails BEAUTIFUL and SHIFT. Position of If-inhibitor ivabradine in current guidelines on management of patients with stable angina and heart failure is discussed.

Topics: Angina Pectoris; Benzazepines; Cardiovascular Agents; Cyclic Nucleotide-Gated Cation Channels; Disease Progression; Evidence-Based Medicine; Heart Failure; Heart Rate; Hospitalization; Humans; Ivabradine; Practice Guidelines as Topic; Randomized Controlled Trials as Topic

Despite significant advances in revascularization techniques and medical therapy, there remains a significant population of patients who continue to have intractable angina symptoms. This review aims to define the patients with refractory angina pectoris (RAP) and to present the therapeutic options currently available for this condition. RAP itself is defined and the pharmacological treatment options other than traditional medical therapies are discussed. The latest therapeutic options for this patient population are extensively reviewed. Among the multitude of pharmacological and non-invasive therapeutic options for patients with RAP, ranolazine is a new drug indicated for the treatment of chronic angina, in combination with amlodipine, beta-blockers or nitrates. Enhanced external counterpulsation has not only been shown to improve symptoms, but also to improve long-term ventricular function in these patients. In randomized trials, neurostimulation has been shown to be effective in reducing angina symptoms. Transmyocardial laser revascularization has emerged as an invasive treatment for RAP over the last two decades. Extracorporeal shockwave myocardial revascularization gene therapy and percutaneous in situ coronary venous arterialization are still under investigation.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Counterpulsation; Drug Therapy, Combination; Electric Stimulation Therapy; Humans; Myocardial Revascularization; Treatment Outcome

Coronary artery disease is a leading cause of death in the United States. Angina is encountered frequently in clinical practice. Effective management of patients with coronary artery disease and stable angina should consist of therapy aimed at symptom control and reduction of adverse clinical outcomes. Therapeutic options for angina include antianginal drugs: nitrates, beta-blockers, calcium channel blockers, ranolazine, and myocardial revascularization. Recent trials have shown that although revascularization is slightly better in controlling symptoms, optimal medical therapy that includes aggressive risk factor modification is equally effective in reducing the risk of future coronary events and death. On the basis of the available data, it seems appropriate to prescribe optimal medical therapy in most patients with coronary artery disease and stable angina, and reserve myocardial revascularization for selected patients with disabling symptoms despite optimal medical therapy.

Topics: Acetanilides; Adrenergic beta-Antagonists; Angina Pectoris; Angiotensin-Converting Enzyme Inhibitors; Benzazepines; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Humans; Hypolipidemic Agents; Ivabradine; Myocardial Revascularization; Nitrates; Piperazines; Ranolazine; Treatment Outcome

A 37-year-old man is admitted to the hospital for retrosternal chest pain lasting more than 30  min and nonspecific ECG findings. Serial assays of cardiac biomarkers reveal an isolated elevation of creatine kinase-MB and negative troponin levels. A coronary angiography shows normal vessels in the presence of a Thrombolysis in Myocardial Infarction (TIMI) 2 flow. How should this patient be managed and treated? Is it a myocardial infarction? We here provide a review of the relevant literature and suggest that such a strange condition, for which several explanations are possible, involves a worse prognosis than for normal creatine kinase-MB and troponins.

Topics: Acute Coronary Syndrome; Adult; Angina Pectoris; Biomarkers; Cardiovascular Agents; Coronary Angiography; Creatine Kinase, MB Form; Drug Therapy, Combination; Electrocardiography; Humans; Male; Predictive Value of Tests; Time Factors; Treatment Outcome; Troponin; Up-Regulation

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiology; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Evidence-Based Medicine; Humans; Patient Selection; Risk Assessment; Treatment Outcome

Heart rate is a major determinant of cardiac output, myocardial oxygen consumption and coronary blood flow under physiological and pathological conditions. Experimental and clinical data have demonstrated that heart rate reduction is the main mechanism for reducing ischemia, improving left ventricular function, decreasing the risk of plaque rupture and post myocardial infarction mortality. Nowadays betablockers are the best class of drugs that can lower heart rate in patients with cardiovascular diseases, but sometimes their use is limited by some contraindications. Ivabradine is a new drug that reduces the firing rate of pacemaker cells in the sinoatrial node through a different mechanism with respect to betablockers. The purpose of this review is to investigate the main trials that support Ivabradine adoption in clinical practice.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Benzazepines; Cardiovascular Agents; Cardiovascular Diseases; Clinical Trials as Topic; Cyclic Nucleotide-Gated Cation Channels; Heart Failure; Heart Rate; Humans; Ivabradine; Myocardial Ischemia; Prognosis; Sinoatrial Node

Coronary artery disease remains the leading cause of mortality in most industrialized countries, although age-standardized mortality related to coronary artery disease (CAD) has decreased by more than 40% during the last two decades. Coronary atherosclerosis may cause angina pectoris, myocardial infarction, heart failure, arrhythmia, and sudden death. Medical management of atherosclerosis and its manifestation aims at retardation of progression of plaque formation, prevention of plaque rupture, and subsequent events and treatment of symptoms, when these occur as well as treatment of the sequelae of the disease. Revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) is performed as treatment of flow-limiting coronary stenosis to reduce myocardial ischaemia. In high-risk patients with acute coronary syndromes (ACS), a routine invasive strategy with revascularization in most patients provides the best outcome with a significant reduction in death and myocardial infarction compared with an initial conservative strategy. Conversely, the benefit of revascularization among patients with chronic stable CAD has been called into question. This review will provide information that revascularization exerts favourable effects on symptoms, quality of life, exercise capacity, and survival, particularly in those with extensive CAD and documented moderate-to-severe ischaemia. Accordingly, CABG and PCI should be considered a valuable adjunct rather than an alternative to medical therapy.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Incidence; Male; Middle Aged; Myocardial Ischemia; Myocardial Revascularization; Prevalence; Risk Assessment; Stents

Anginal chest pain is one of the most common complaints in the outpatient setting. While much of the focus has been on identifying obstructive atherosclerotic coronary artery disease (CAD) as the cause of anginal chest pain, it is clear that microvascular coronary dysfunction (MCD) can also cause anginal chest pain as a manifestation of ischemic heart disease, and carries an increased cardiovascular risk. Epicardial coronary vasospasm, aortic stenosis, left ventricular hypertrophy, congenital coronary anomalies, mitral valve prolapse, and abnormal cardiac nociception can also present as angina of cardiac origin. For nonacute coronary syndrome (ACS) stable chest pain, exercise treadmill testing (ETT) remains the primary tool for diagnosis of ischemia and cardiac risk stratification; however, in certain subsets of patients, such as women, ETT has a lower sensitivity and specificity for identifying obstructive CAD. When combined with an imaging modality, such as nuclear perfusion or echocardiography testing, the sensitivity and specificity of stress testing for detection of obstructive CAD improves significantly. Advancements in stress cardiac magnetic resonance imaging enables detection of perfusion abnormalities in a specific coronary artery territory, as well as subendocardial ischemia associated with MCD. Coronary computed tomography angiography enables visual assessment of obstructive CAD, albeit with a higher radiation dose. Invasive coronary angiography remains the gold standard for diagnosis and treatment of obstructive lesions that cause medically refractory stable angina. Furthermore, in patients with normal coronary angiograms, the addition of coronary reactivity testing can help diagnose endothelial-dependent and -independent microvascular dysfunction. Lifestyle modification and pharmacologic intervention remains the cornerstone of therapy to reduce morbidity and mortality in patients with stable angina. This review focuses on the pathophysiology, diagnosis, and treatment of stable, non-ACS anginal chest pain.

Topics: Age Factors; Angina Pectoris; Cardiovascular Agents; Chest Pain; Coronary Disease; Diagnosis, Differential; Diagnostic Imaging; Electrocardiography; Exercise Test; Female; Humans; Male; Myocardial Revascularization; Risk Factors; Sex Factors; Syndrome

Despite improved mortality and morbidity in the treatment of coronary artery disease, a significant proportion of patients will continue to experience recurrent angina pectoris.. Anti-anginal therapy has long been dominated by the use of beta-blockers, Ca(2+) channel blockers and nitrates. Most recently, ranolazine was introduced as a new anti-anginal class. This review article presents current and novel anti-anginal strategies under development. A discussion of their molecular mechanisms that may complement traditional therapies is presented. Medline and PubMed scientific search tools were primarily used to identify relevant literature dating from 1970 to 2008.. This review provides a summary of both traditional and emerging therapeutic approaches to angina pectoris management. A discussion on the mechanism of action and clinical efficacy of ranolazine, trimetazidine, nicorandil, ivabradine, fasudil and growth factor gene therapy as anti-anginal agents is provided.. The need for multiple approaches cannot be over-emphasized. Availability of various modalities would strongly enhance the ability to meet the needs of a heterogeneous patient population. Patients with recurrent angina pectoris most likely will require multi-drug regimen where different mechanisms may complement each other and result in a more efficacious strategy.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Drugs, Investigational; Genetic Therapy; Humans; Intercellular Signaling Peptides and Proteins; Recurrence; Treatment Outcome

Angina pectoris, the pain of myocardial ischemia, is the major initial and subsequent presentation of coronary disease in women. Angina in women is associated with more adverse morbidity, mortality, and quality-of-life outcomes than for men, despite women having less obstructive coronary artery disease and better left ventricular function. Women with chest pain and myocardial ischemia, in the absence of significant obstructive disease of the coronary arteries, have prominent morbidity and mortality outcomes; the postulated mechanism is microvascular disease. Women also have more non-chest pain manifestations of myocardial ischemia than men. These variables must be incorporated in assessments of optimal diagnostic and therapeutic strategies for myocardial ischemia in women.

Topics: Angina Pectoris; Cardiovascular Agents; Chest Pain; Coronary Disease; Coronary Vessels; Female; Humans; Myocardial Ischemia; Prognosis; Quality of Life; Risk Factors; United States

Ischemic heart disease is the major cause of morbidity and mortality in the Western world. Patients often suffer a reduction in quality of life due to chronic stable angina, but therapeutic options can be limited due to concerns for heart rate and blood pressure, as well as side effect profiles. Even revascularization therapy has its limitations and newer agents are required to help in this battle for symptomatic relief. Ranolazine (Ranexa(R), A. Menarini Pharma UK, High Wycombe, UK) is a drug with a novel mechanism of action that has been shown in several large trials to be an efficacious adjunctive agent in reducing symptoms of chronic stable angina. It is thought to work by inhibiting the late sodium current in cardiac myocytes, thereby reducing sodium and calcium overload that follows ischemia. This improves myocardial relaxation and reduces left ventricular diastolic stiffness, which in turn enhances myocardial contractility and perfusion. The drug is generally well tolerated and the evidence so far is encouraging, with a clear clinical benefit achieved in the target groups. Its main strength is that it does not appear to affect either heart rate or blood pressure. This review provides an insight into this treatment option, describes the clinical trials evidence, proposed mechanism of action, and pharmacokinetics, and outlines the indications for its use in chronic stable angina.

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Bypass; Drug Therapy, Combination; Humans; Piperazines; Randomized Controlled Trials as Topic; Ranolazine

The classification of patients with angina pectoris into various subgroups, which clearly differ in risk based on the patient's characteristics, is difficult. Changes in pain threshold occur frequently. The variation in intensity of the "chest discomfort" makes the history and physical of limited value in making the diagnosis. It may be necessary to use noninvasive testing to demonstrate myocardial ischemia and/or coronary angiography to define stenotic coronary artery stenosis. Within the past 30 years, there have been major advances in the successful medical and invasive treatment of angina pectoris. There are now several forms of effective therapy, which are discussed in detail in this monograph.

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Evidence-Based Medicine; Heart Function Tests; Humans; Myocardial Revascularization; Predictive Value of Tests; Risk Factors; Severity of Illness Index; Treatment Outcome

This review outlines the evolving role of percutaneous coronary intervention (PCI) for stable angina in the context of the widely discussed Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trials. Factors outlined include defining the appropriate patient population, the clinical circumstances, and the technical aspects of the procedure to optimize clinical outcomes and minimize risk. The COURAGE Trial, as others reported earlier, reported no difference in death or myocardial infarction with PCI compared with medical therapy for stable angina. In patients with type 2 diabetes mellitus in the BARI 2D Trial, a strategy of revascularization with coronary artery bypass graft surgery (CABG) or PCI resulted in no difference in mortality compared with optimal medical therapy. However, PCI for stable angina was associated with reduced angina and improved quality of life. Procedural aspects of PCI that support its continuing role in the management of patients with stable angina include the frequent advancements in PCI technology that have further enhanced both acute and long-term success. In conclusion, the implications of these findings for clinical practice include evaluating the use of PCI for stable angina in addition to optimal medical therapy to reduce angina and improve quality of life, but individualizing care for higher risk patients with more complex coronary artery disease who were not enrolled in the COURAGE and BARI 2D trials.

Topics: Angina Pectoris; Angioplasty; Cardiovascular Agents; Case Management; Coronary Artery Bypass; Coronary Artery Disease; Diabetes Mellitus, Type 2; Humans; Quality of Life; Randomized Controlled Trials as Topic; Risk Factors; Secondary Prevention; Treatment Outcome

Effective management of stable angina usually includes drug therapy. There are several agents that are considered vasculoprotective such as aspirin, angiotensin converting enzyme inhibitors and statins. Conventional anti ischemic therapy includes nitrates, beta-blockers and calcium-channel blockers. In recent years, several other drugs with novel anti ischemic mechanisms have become available including ranolazine, ivabradine, nicorandil and many others. This article reviews drugs that alleviate the symptoms of chronic angina with emphasis on several novel pharmacological agents.

Topics: Acetanilides; Adrenergic beta-Antagonists; Angina Pectoris; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Benzazepines; Calcium Channel Blockers; Cardiovascular Agents; Cardiovascular System; Coronary Artery Disease; Hemodynamics; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Ivabradine; Nicorandil; Nitrates; Piperazines; Ranolazine

In November 2009 the first European guidelines were presented regarding preoperative risk assessment and perioperative management in non-cardiac surgery. They were designed by the European Society of Cardiology (ESC) and endorsed by the European Society of Anesthesiology.In a standardized manner, patient-specific clinical variables, their exercise capacity and surgery-specific risk factors are summarized to a recommendation concerning medication and preoperative cardiac evaluation. These guidelines are straightforward and feasible for cardiologists as well as specialists in internal medicine and general practicioners. Nevertheless, some points still lack evidence.

Topics: Activities of Daily Living; Age Factors; Angina Pectoris; Cardiovascular Agents; Cardiovascular Diseases; Cerebrovascular Disorders; Coronary Angiography; Diabetes Mellitus, Type 1; Electrocardiography; Europe; Evidence-Based Medicine; Exercise Test; Health Status Indicators; Heart Failure; Humans; Metabolic Equivalent; Practice Guidelines as Topic; Preoperative Care; Renal Insufficiency

Chronic stable angina pectoris (CSAP) usually occurs in patients with coronary artery disease (CAD) that affects one or more large epicardial arteries. It results when myocardial perfusion is insufficient to meet cardiac metabolic demand. Elevated heart rate (HR) is an important factor in the development of myocardial ischemia and angina pectoris. The pharmacologic agents most commonly administered in the treatment of CSAP are beta-blockers and calcium channel blockers (CCBs). However, the use of beta-blockers is limited by poor compliance related to contraindications and comorbidities, especially in elderly patients. Ivabradine is a new selective HR-lowering agent that selectively inhibits the pacemaker current I (f) in the sinus atrial node. In several randomized controlled trials, ivabradine 5-10 mg twice daily has demonstrated equivalent anti-ischemic and anti-anginal activity to beta-blockers and CCBs, with a good safety and tolerability profile. Although ivabradine has been shown not to improve cardiac outcomes in patients with stable CAD and left ventricular systolic dysfunction, it may be used to reduce the incidence of CAD outcomes in a subgroup of patients with HR > or =70 bpm. The aim of this short review is to summarize the use of ivabradine in the treatment of CSAP, and its potential utility in atherosclerosis, primitive and dilatative cardiomyopathy, and arrhythmias, such as postural tachycardia syndrome and inappropriate sinus tachycardia, where exclusive lowering of elevated HR may prove beneficial.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Benzazepines; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Disease; Heart Failure; Heart Rate; Heart Transplantation; Humans; Ivabradine; Nitrates; Randomized Controlled Trials as Topic; Ventricular Dysfunction, Left

Angina pectoris is a cardiac condition characterized by an insufficient perfusion to meet myocardial metabolic demand. A high heart rate represents an important factor in the induction of myocardial ischemia and subsequent angina. beta-blocker drugs are effective at reducing angina pectoris by decreasing the heart rate and are usually preferred as initial therapy in the absence of contraindication or intolerance. Ivabradine, a new oral drug for the symptomatic treatment of chronic stable angina pectoris, decreases the resting heart rate of patients with normal sinus rhythm. In many clinical trials, ivabradine has been directly compared with placebo, beta-blocker drugs (e.g., atenolol and propranolol) and calcium channel blockers (e.g., amlodipine). These studies have demonstrated ivabradine, given in doses of 5-10 mg twice daily, to be more effective than placebo for increasing time to angina onset and noninferior to atenolol 50-100 mg daily and amlodipine 10 mg daily for increasing total exercise duration in patients with chronic stable angina. Visual symptoms, a transient, enhanced brightness in a limited area of the visual field known as luminous phenomena or phosphenes, were the most common adverse effects in clinical trials. This article aims to provide a research update regarding this new drug, based on a literature search.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Animals; Benzazepines; Cardiovascular Agents; Clinical Trials as Topic; Heart Rate; Humans; Ivabradine; Risk Factors; Vision Disorders

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial was designed to determine whether percutaneous coronary intervention (PCI) coupled with optimal medical therapy (OMT) reduced the risk of death or nonfatal myocardial infarction in patients with stable coronary artery disease as compared with OMT alone. COURAGE demonstrated that an initial strategy of PCI added to OMT in these patients relieved angina to a greater extent than an initial strategy of OMT alone for a period of approximately 24 months. The initial strategy of PCI (plus OMT) did not reduce death, myocardial infarction, or other major cardiovascular events compared with OMT alone. The important quality-of-life findings permit physicians to engage in an evidence-based discussion with patients about the expected clinical and health status benefits of initial versus deferred PCI when added to OMT.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Combined Modality Therapy; Coronary Artery Disease; Evidence-Based Medicine; Humans; Multicenter Studies as Topic; Myocardial Infarction; Patient Selection; Quality of Life; Risk Assessment; Time Factors; Treatment Outcome

Although advances in percutaneous catheter-based interventions (PCI) for coronary artery disease have been associated with reductions in angiographic as well as clinical restenosis, no consistent reduction in the occurrence of death or nonfatal myocardial infarction (MI) has been observed either between devices (balloon vs bare-metal stent vs drug-eluting stent [DES]) or between device and medically treated patients with chronic stable coronary disease. Objective evidence of myocardial ischemia--irrespective of the methodology used to demonstrate its presence--is qualitatively and quantitatively related to the occurrence of death and/or nonfatal MI. The magnitude of ischemia is directly proportional to the magnitude of revascularization benefit (reduction in death or MI). Revascularization by PCI is more effective in reducing ischemia than medical therapy alone. The evolution of both PCI technology (DES) and adjunctive pharmacology has improved the relative magnitude and durability of PCI benefit compared with medical therapy alone.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Combined Modality Therapy; Coronary Artery Disease; Evidence-Based Medicine; Humans; Multicenter Studies as Topic; Myocardial Infarction; Myocardial Ischemia; Patient Selection; Risk Assessment; Time Factors; Treatment Outcome

The primary objective of treatment in patients with chronic coronary artery disease (CAD) and stable angina is relief of symptoms and improvement of clinical outcome. The American College of Cardiology/American Heart Association guidelines have emphasized the role of evidence-based therapies. There have been regular updates of the guidelines, with an effort to include the latest data in the recommendations. Since the 2002 guidelines were published, there have been several pivotal studies that have provided strong support for the role of aggressive and optimal medical therapy in improving clinical outcomes in patients with chronic CAD. Recent data from 2 landmark studies have emphasized that optimal medical therapy is as effective as myocardial revascularization with percutaneous coronary intervention or coronary artery bypass grafting in reducing risk of adverse clinical outcomes. The 2009-2010 guidelines will likely incorporate the findings of these studies and accordingly modify the recommendations for treatment of patients with chronic CAD and stable angina.

Topics: American Heart Association; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Drug Therapy, Combination; Evidence-Based Medicine; Humans; Myocardial Revascularization; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Treatment Outcome; United States

Medical therapy is the standard background treatment for all patients with chronic stable angina. Studies show that antianginal therapies such as late sodium channel blockers (ranolazine), beta-blockers, calcium channel blockers, and nitrates dispensed alone or in combination can alleviate angina and angina-equivalent symptoms. For risk reduction of ischemic events, modification of coronary risk factors with lifestyle modification and medical therapy is the cornerstone. Effective risk modification strategies include lipid management, smoking cessation, diabetes control, weight management, nutritional enhancements, and physical activity. The pursuit of a more definitive treatment for chronic angina should be guided by the patient's clinical presentation, results of imaging-based risk-stratification evaluations, response to medical therapies, and patient preference. Revascularization by percutaneous coronary intervention or coronary artery bypass surgery may be recommended for patients who have persistent and intolerable symptoms despite optimal medical therapy and for those who are likely to have a survival benefit from revascularization based on the severity and location of the atherosclerotic lesions.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Artery Bypass; Coronary Artery Disease; Evidence-Based Medicine; Humans; Patient Selection; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Treatment Outcome

Chronic angina is a prevalent manifestation of cardiovascular disease and is most commonly due to insufficient oxygen supply from fixed epicardial lesions in the coronary arteries. In addition to increasing the risk of cardiovascular death and recurrent myocardial infarction, chronic angina has a significant impact on functional capacity and quality of life. All patients with cardiovascular disease should be closely questioned to determine the functional and symptomatic limitations attributable to ischemic symptoms. The Canadian Cardiovascular Society Classification of Angina is the easiest metric to use; however, more sensitive measures such as the Seattle Angina Questionnaire offer a better overall assessment of angina symptoms and quality of life and can be used to compare the efficacy of different treatments. Treatment strategies that begin with either immediate revascularization or optimal medical therapy with antianginal agents significantly improve angina frequency and quality of life. Initial revascularization, especially with coronary artery bypass grafting, appears to offer more rapid relief of angina compared with percutaneous coronary intervention or medical therapy in the first months after initial revascularization. After a year of follow-up, though, much of the treatment differences are lost and all strategies (surgical/percutaneous revascularization or medical therapy) result in a significant improvement of angina symptoms.

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Coronary Circulation; Humans; Myocardial Revascularization; Prevalence; Quality of Life; Recovery of Function; Surveys and Questionnaires; Time Factors; Treatment Outcome

Transient cardiac ballooning is usually a reversible clinical entity. A patient typically presents with chest pain, electrocardiogram (ECG) abnormalities like ST-segment elevation (most commonly reported) or depression, and elevated cardiac enzymes, but has no or nonobstructive coronary artery disease. Left ventriculography reveals transient akinesis of the involved portion of the myocardial wall with compensatory hyperkinesis of the remaining myocardium, leading to ballooning of the noncontracting myocardial wall during systole. Acute regional myocardial dysfunction ensues, which normalizes on average within 1 to 6 weeks. The hypotheses for these pathophysiologic changes range from direct cardiac myocyte injury to postischemic myocardial stunning to neurotransmitter actions. The objective of this article is to present a succinct description of a small case series accompanied with various recently reported presentations and morphology by left ventriculogram and a detailed review of available data on underlying pathophysiology. In addition, a discussion on current diagnostic guidelines, treatment, prognosis, and potential future investigations is included.

Topics: Adult; Aged; Angina Pectoris; Biomarkers; Cardiovascular Agents; Coronary Angiography; Electrocardiography; Female; Heart Ventricles; Humans; Middle Aged; Myocardium; Practice Guidelines as Topic; Stress, Psychological; Stroke Volume; Takotsubo Cardiomyopathy; Treatment Outcome; Up-Regulation; Ventricular Function, Left

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Humans

"Metabolic treatment" involves the use of drugs to improve cardiomyocyte function. Trimetazidine is the most investigated drugs in this group. The ESC 2006 guidelines on the management of patients with stable angina mention the efficacy of metabolic treatment in improving physical efficiency and decreasing the recurrence of pain. The available data suggest that combined therapy of trimetazidine and haemodynamic drugs is an effective antianginal treatment that reduces the risk of pain recurrence (in as many as 64% of patients). The most recent studies also suggest that trimetazidine might be effective in patients with acute coronary syndromes, ischemic cardiomyopathy and heart failure. However, while trimetazidine has shown beneficial effects on surrogate endpoints in several small trials its effect on cardiovascular events is uncertain. Further large randomized studies are needed before its effects on cardiovascular events can be evaluated.

Topics: Acute Coronary Syndrome; Angina Pectoris; Cardiovascular Agents; Energy Metabolism; Humans; Myocardial Infarction; Myocardium; Practice Guidelines as Topic; Treatment Outcome; Trimetazidine

Extended-release ranolazine (ranolazine ER) [Ranexa] is a piperazine derivative with a novel mechanism of action that was recently approved in the EU for use as add-on therapy in patients with stable angina pectoris. Ranolazine ER achieves its antianginal effect without affecting heart rate or blood pressure (BP) to a clinically significant extent. Results of well designed, placebo-controlled, short-term studies demonstrate that add-on therapy with ranolazine ER in patients with chronic stable angina improves exercise performance, and reduces anginal frequency and nitroglycerin use. Although longer-term therapy with ranolazine ER did not reduce the incidence of major cardiovascular events in patients with non-ST-elevation acute coronary syndromes, it did reduce the incidence of recurrent ischaemia. Ranolazine ER is a generally well tolerated antianginal agent. Although it is associated with modest dose-related increases in the corrected QT (QTc) interval, ranolazine ER does not appear to be associated with an excess of arrhythmias. Thus, ranolazine ER is a useful new option for patients with chronic stable angina whose symptoms are not controlled with first-line antianginal therapy or who do not tolerate first-line antianginal agents.

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Delayed-Action Preparations; Humans; Piperazines; Ranolazine

Refractory angina pectoris is a common clinical condition associated with significant morbidity and mortality. This review aims to provide a systematic approach to the assessment and treatment of patients with this condition, focusing particularly on recent data.. Recent registry-based data have confirmed that a significant proportion of patients referred to cardiologists are suffering from refractory angina pectoris and that this is associated with poor quality of life and increased mortality. A number of novel antianginal drugs have been developed, although there has been little consensus on their use in the treatment of refractory angina. In addition, multiple interventional treatments are available but detailed evaluation is sparse. More recent studies have begun to address some of the major concerns associated with the use of these technologies, including the placebo effect. Studies comparing the different techniques are now beginning to emerge, allowing clinicians and patients to make informed choices.. A systematic approach is needed for the assessment and treatment of patients with refractory angina pectoris. Further research must include carefully designed randomized placebo-controlled trials to enable the role and application of the different techniques to be defined.

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Patient Education as Topic; Vasodilator Agents

Chronic stable angina is a debilitating illness affecting at least 6.6 million US residents. Despite being optimally treated by pharmacotherapy and revascularization up to 26% of patients still experience angina. Diabetes mellitus is a common co-morbid condition in angina patients. Several new investigational medications are being tested for chronic angina. Advances in understanding of myocardial ischemia have prompted evaluation of a number of new antianginal strategies. In this review we discuss the utility of ranolazine, a recently approved novel antianginal agent and its efficacy in the diabetic patient population. In addition to its antianginal action in diabetic patients with chronic angina, ranolazine may have favorable effects on glycated hemoglobin levels.

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Diabetes Complications; Glycated Hemoglobin; Humans; Piperazines; Ranolazine; Treatment Outcome

Stable angina is usually caused by coronary atherosclerosis, and affects up to 16% of men and 10% of women aged 65-74 years in the UK. Risk factors include hypertension, elevated serum cholesterol levels, smoking, physical inactivity, and overweight. People with angina are at increased risk of other cardiovascular events and mortality compared with people without angina. Among people not thought to need coronary artery revascularisation, annual mortality is 1-2% and the annual non-fatal myocardial infarction (MI) rate is 2-3%.. We conducted a systematic review and aimed to answer the following clinical question: What are effects of long-term drug treatment for stable angina? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).. We found nine systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.. In this systematic review we present information relating to the long-term effectiveness and safety of the following interventions: beta-blockers, calcium channel blockers, long-acting nitrates, potassium channel openers, combinations of these anti-anginal drug treatments and the use of these anti-anginal drug treatment as an adjunct to existing therapies.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Humans; Incidence; Myocardial Infarction; Prospective Studies; Risk Factors

The author summarizes the evidences of angina pectoris' optimal treatment. The invasive treatment strategy became a frontrunner in this field as well. During the last years the number of percutaneous interventions became higher than bypass operations in many countries as well as in Hungary. The place of percutaneous interventions and bypass surgery in the treatment of angina pectoris is an important clinical problem. The author summarizes the data of three possible treatment options (medical therapy, percutaneous interventions and bypass surgery) of angina pectoris based on data of randomised trials. The evidences show that the first steps of therapy are - after the diagnosis - the influence of risk factors, life-style changes and optimal medical therapy. The optimal medical therapy consists of statin, aspirin and ACE inhibitor treatment besides antianginal therapy, where the beta blockers are regarded as first drugs of choice. Percutaneous interventions as initial treatment option are not recommended because we have no evidences that this intervention prolongs life and prevents myocardial infarction. If the patient remains symptomatic after medical treatment, it is necessary to perform revascularization. These procedures can improve the functional capacity more than medical treatment alone. The optimal treatment strategy of angina pectoris, based on evidence, is an important medical and economical problem.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Evidence-Based Medicine; Exercise Test; Humans; Life Style; Myocardial Infarction; Predictive Value of Tests; Prognosis; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors

With the spread of invasive cardiology, and with the opening of new home centers today coronarography and the necessary coronary revascularization are accessible for everyone. The indication of invasive investigation of the acute coronary diseases (STEMI, NSTE-ACS) is crystallised by today. At the same time the indication that the invasive strategy of stable coronary disease depends on more factors, this is a complex exercise. This contains the clinical risk stratification (among the analysis of the classic risk factors), and measures the ejection fraction, and the result of the exercise test and the anatomically risk stratification - based on the coronarography. Authors summarised the clinical risk stratification and the indication of the invasive investigation of the stable coronary disease, based on the recent clinical trials and the guidelines.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Decision Trees; Evidence-Based Medicine; Humans; International Cooperation; Life Style; Multicenter Studies as Topic; Myocardial Infarction; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors

Angina pectoris can result in an imbalance between oxygen supply and demand of the heart muscle, resulting in a compromised energy supply to the heart muscle. Currently, the primary approach to treating angina is aimed either at decreasing muscle oxygen demand, or increasing oxygen supply to the muscle. An alternative approach is to increase cardiac efficiency by increasing the amount of cardiac work at a given level of oxygen consumed. This can be achieved by inhibiting myocardial fatty acid oxidation, which leads to an increase in glucose oxidation. Consequently, lactate and proton production decrease, and as a result cardiac efficiency is improved. The approach of partial fatty acid oxidation (pFOX) inhibition is beneficial in the treatment of angina pectoris, both as a monotherapy and when used in combination with conventional therapy. pFOX inhibitors not only lessen the severity and symptoms of an angina attack, they also decrease the incidence of angina attacks in patients with coronary artery disease. The approach of optimizing energy substrate preference in the heart is a new and effective approach to treating angina pectoris.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Coronary Artery Disease; Energy Metabolism; Fatty Acids; Humans; Myocardial Contraction; Myocardial Ischemia; Oxidation-Reduction

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Diagnosis, Differential; Echocardiography; Electrocardiography; Humans; Myocardial Infarction; Prognosis

The elderly constitute an increasingly important sector of patients with acute coronary syndromes (ACS), although they have been under-represented in many therapeutic trials. Elderly patients with ACS usually have more complex co-morbidities and worse outcomes than their younger counterparts, and they are less likely to undergo revascularisation or to receive short- and long-term evidence-based medications. The most common ACS in the elderly is non-ST-segment elevation myocardial infarction (STEMI), which is associated with high mortality. For this reason, elderly patients with non-STEMI and unstable angina should be treated invasively early in the course of the episode. In elderly patients with STEMI, primary angioplasty seems to be more effective than fibrinolysis, and in patients aged >85 years a more conservative approach to fibrinolysis is also warranted because of the higher risk for cerebral haemorrhage. Therefore, angioplasty should be preferred when feasible, although more trials are needed before this strategy can definitely be documented as the preferred option. Drug-eluting stents afford greater benefit than bare metal stents in elderly patients and are more cost effective. After fibrinolysis, low-molecular-weight heparin appears to be superior to unfractionated heparin in elderly patients with STEMI but major bleeding and intracranial haemorrhages occur more frequently, especially in women aged >75 years. It is very important to understand that the elderly with ACS constitute a subgroup of atherosclerotic patients for whom decision making must be guided by the patients''physiological age' (determined by their physical condition and other co-morbidities) and not strictly by their 'chronological age'.

Topics: Acute Coronary Syndrome; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Drug-Eluting Stents; Fibrinolytic Agents; Humans; Middle Aged; Myocardial Infarction; Prognosis; Shock, Cardiogenic; Stents

Cardiovascular diseases, the clinical paradigm of atherosclerosis, are the primary cause of mortality in developed countries. The origin of the atheromatous lesion is multifactorial, as it is the therapeutic approach to its prevention and clinical complications. The initial symptoms of ischemia in a vascular bed are usually evident when the atherosclerotic process is very advanced, being indicative of a diffuse disease and of an elevated future risk for ischemic events in other vascular territories. We perform this review in this clinical scenario, highlighting the preventive and therapeutic aspects of demonstrated clinical efficacy, with no detail of those treatments with benefit insufficiently proven.

Topics: Angina Pectoris; Anticoagulants; Atherosclerosis; Brain Ischemia; Cardiovascular Agents; Combined Modality Therapy; Heart Failure; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Myocardial Infarction; Myocardial Ischemia; Peripheral Vascular Diseases; Platelet Aggregation Inhibitors; Risk Factors

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Artery Bypass; Humans; Patient Selection; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Stents; Treatment Outcome

Despite tremendous success of growth factor therapy in animal models, clinical trials have demonstrated minimal success. Vascular endothelial growth factors are perhaps the most potent inducers of angiogenesis in these animal models. This review outlines the biology of vascular endothelial growth factors in the context of myocardial angiogenesis with an emphasis on its effects on the endothelium. It also provides an overview of delivery strategies and summarises the preclinical and clinical evidence relating to exogenous growth factor delivery for myocardial angiogenesis with an emphasis on the key future challenges.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Drug Delivery Systems; Humans; Vascular Endothelial Growth Factor A

Chronic refractory angina is a term used to describe patients who, despite optimal medical therapy, have both angina and objective evidence of ischaemia. It is estimated that 5-15% of the 12 million patients with chronic angina in the US meet the criteria for having refractory angina. This review focuses on the following evolving pharmacological therapies for chronic refractory angina: L-arginine, ivabradine, ranolazine, nicorandil and trimetazidine. Evolving devices and invasive procedures including enhanced external counterpulsation, spinal cord stimulation, and transmyocardial revascularisation are also briefly discussed.

Topics: Acetanilides; Angina Pectoris; Arginine; Benzazepines; Cardiovascular Agents; Chronic Disease; Combined Modality Therapy; Counterpulsation; Electric Stimulation Therapy; Humans; Ivabradine; Myocardial Revascularization; Piperazines; Randomized Controlled Trials as Topic; Ranolazine; Spinal Cord

The ever-increasing burden of ischaemic heart disease and its common manifestation chronic angina pectoris calls for the exploration of other treatment options for those patients who despite the maximum conventional pharmacological and surgical interventions continue to suffer. Such exploration has led to the increasing use of new metabolically acting antianginal agents and the re-emergence of an old and somewhat forgotten pharmacological agent, perhexiline maleate. This review aims to update the cardiac nurse with knowledge to manage the care a patient receiving perhexiline maleate treatment and provide a brief review of three new metabolic agents: trimetazidine, ranolazine and etomoxir.

Topics: Acetanilides; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Carnitine O-Palmitoyltransferase; Drug Monitoring; Epoxy Compounds; Fatty Acids; Half-Life; Humans; Metabolic Clearance Rate; Nurse's Role; Nursing Assessment; Patient Education as Topic; Patient Selection; Perhexiline; Piperazines; Randomized Controlled Trials as Topic; Ranolazine; Treatment Outcome; Trimetazidine; Vasodilator Agents

Ranolazine (Ranexa), a piperazine derivative, is a new antianginal agent approved for the treatment of chronic stable angina pectoris for use as combination therapy when angina is not adequately controlled with other antianginal agents. While the exact mechanism of action of ranolazine is not known, its antianginal and anti-ischaemic effects do not appear to depend upon changes in blood pressure or heart rate. An extended-release (ER) oral formulation of ranolazine has been developed to facilitate twice-daily administration whilst maintaining therapeutically effective plasma concentrations. In patients with chronic stable angina, ranolazine ER monotherapy was shown to improve exercise duration at trough plasma drug concentration in a dose-dependent manner compared with placebo. The drug was effective as adjunctive therapy in patients with chronic stable angina whose condition was not controlled adequately with conventional antianginal therapy. In randomised clinical trials, ranolazine ER was well tolerated, with no overt effects on cardiovascular haemodynamics or conduction, apart from a modest increase in corrected QT (QTc) interval (but no torsades de pointes). Importantly, the efficacy and tolerability of ranolazine ER were not affected by comorbid conditions, including old age, heart failure (HF) or diabetes mellitus. Comparative trials of ranolazine ER with other antianginal agents and trials examining its effects on long-term morbidity and mortality in patients with ischaemic heart disease are required to determine with greater certainty the place of the drug in current antianginal therapy. Nevertheless, ranolazine ER may well prove to be a useful alternative and adjunct to conventional haemodynamic antianginal therapy in the treatment of chronic stable angina.

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Humans; Piperazines; Randomized Controlled Trials as Topic; Ranolazine

Stable angina pectoris is a manifestation of ischemic heart disease which frequently leeds to acute coronary syndrome. The patient has a short effort or stress situation induced retrosternal pain which is easing after the elimination of its cause, or taking nitroglycerin. Several new data have appeared in the literature about the pathogenesis and diagnosis of stable angina pectoris. Due to the international guidelines using the new drugs and revascularisation techniques, the primary and secondary prevention of stable angina pectoris was improved.

Topics: Acute Disease; Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Humans; Myocardial Ischemia; Syndrome

Rho-kinase is a signaling molecule that occurs downstream of the small GTPase Rho, which mediates various cellular functions. The Rho/Rho-kinase pathway plays an important role in pathophysiology and progression of various cardiovascular diseases such as hypertension, coronary vasospasm, angina pectoris, and restenosis after percutaneous coronary intervention, all of which are related to arteriosclerosis/atherosclerosis changes of the vasculature. Activation of the Rho/Rho-kinase pathway contributes to inflammatory and proliferative changes of the blood vessels and affects cardiac myocytes. Evidence from in vitro and in vivo studies suggests that Rho-kinase inhibitors have beneficial effects on cardiovascular diseases, particularly arteriosclerosis and coronary vasospasm. Furthermore, activation of the Rho/Rho-kinase pathway contributes to blood pressure regulation via the central sympathetic nervous system. There is evidence to suggest that Rho-kinase is involved in angiotensin II-induced cardiac hypertrophy and endothelial dysfunction, and preliminary data indicate that inhibition of Rho-kinase may be beneficial in vascular disorders such as pulmonary arterial hypertension and erectile dysfunction. Fasudil is currently the only Rho-kinase inhibitor available for clinical use and it is approved in Japan for the prevention of vasospasm in patients with subarachnoid hemorrhage. Emerging clinical data have shown that oral fasudil 80 mg three times daily is effective in preventing myocardial ischemia in patients with stable angina pectoris. Rho-kinase represents a new target for the management of cardiovascular diseases and further studies are needed to define the therapeutic potential of Rho-kinase inhibitors.

Topics: Angina Pectoris; Brain; Cardiovascular Agents; Cardiovascular Diseases; Humans; Hypertension; Intracellular Signaling Peptides and Proteins; Protein Serine-Threonine Kinases; Randomized Controlled Trials as Topic; rho-Associated Kinases

Percutaneous coronary intervention (PCI) has been shown to improve symptoms compared with conservative medical treatment in patients with stable coronary artery disease (CAD); however, there is limited evidence on the effect of PCI on the risk of death, myocardial infarction, and subsequent revascularization. Therefore, we performed a meta-analysis of 11 randomized trials comparing PCI to conservative treatment in patients with stable CAD.. A total of 2950 patients were included in the meta-analysis (1476 received PCI, and 1474 received conservative treatment). There was no significant difference between the 2 treatment strategies with regard to mortality, cardiac death or myocardial infarction, nonfatal myocardial infarction, CABG, or PCI during follow-up. By random effects, the risk ratios (95% CIs) for the PCI versus conservative treatment arms were 0.94 (0.72 to 1.24), 1.17 (0.88 to 1.57), 1.28 (0.94 to 1.75), 1.03 (0.80 to 1.33), and 1.23 (0.80 to 1.90) for these 5 outcomes, respectively. A possible survival benefit was seen for PCI only in trials of patients who had a relatively recent myocardial infarction (risk ratio 0.40, 95% CI 0.17 to 0.95). Except for PCI during follow-up, there was no significant between-study heterogeneity for any outcome.. In patients with chronic stable CAD, in the absence of a recent myocardial infarction, PCI does not offer any benefit in terms of death, myocardial infarction, or the need for subsequent revascularization compared with conservative medical treatment.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Bayes Theorem; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Coronary Stenosis; Death; Female; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Odds Ratio; Randomized Controlled Trials as Topic; Risk Assessment; Treatment Outcome

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

Topics: Age Distribution; Aged; Angina Pectoris; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Coronary Disease; Drug Interactions; Erectile Dysfunction; Humans; Incidence; Male; Middle Aged; Piperazines; Prognosis; Purines; Risk Assessment; Severity of Illness Index; Sildenafil Citrate; Sulfones; Survival Rate

Cardiovascular diseases are the number one cause of death in Germany. In 2002 about 70,000 people died of acute myocardial infarction (AMI) and of these 37% died before arrival at hospital which underlines the relevance of adequate prehospital care. The generic term acute coronary syndrome (ACS) was introduced because a single pathomechanism accounts for the different forms and comprises unstable angina pectoris (iAP), non-ST-elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI) and sudden cardiac death (SCD). Characteristic features are retrosternal pain, vegetative symptoms and radiation of pain into the adjoining regions. Further differentiation can only be achieved by the 12-lead ECG, as cardiac-specific enzymes do not play a role in prehospital decisions. Prehospital delays should be avoided, history and physical examination should be brief but focused, vital parameters should be assessed and monitored. Basic treatment for ACS should comprise inhalative oxygen, nitrates, morphine, aspirin and beta-blockers. If STEMI is diagnosed, patients with symptoms <12 h should undergo fibrinolytic therapy unless there is primary percutaneous coronary intervention (PCI) available within 90 min or if contraindicated. Heparin should be given to patients with STEMI depending on the choice of fibrinolytic agent, it otherwise results in a higher risk of bleeding, but in patients with iAP or NSTEMI it reduces mortality. All patients must be accompanied by the emergency physician during transportation and should be brought to a hospital with primary PCI, especially those with complicated ACS. Treatment of complications depends largely on the type, persistence and severity.

Topics: Acute Disease; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Electrocardiography; Emergency Medical Services; Germany; Humans; Myocardial Infarction

As the US population ages, the pool of patients with coronary artery disease and stable angina is projected to grow. Conventional approaches with mechanical and pharmacological therapies have made inroads toward curbing this trend, reducing the risk of future myocardial infarction and cardiac death. However, the potential benefits of currently available antianginal medications are limited by reduced work capacity, orthostasis, and important drug-drug interactions. A new approach is represented by the piperazine derivatives trimetazidine (TMZ) and ranolazine (RNZ). TMZ acts to partially inhibit fatty acid oxidation, thus shifting myocardial energy metabolism to a lower oxygen-consuming state. A total of 16 randomized trials have been completed with TMZ. In the US market, 6 trials have been completed with RNZ. RNZ has been separately classified as a late sodium channel inhibitor, which reverses action potential prolongation, suppresses early after-depolarizations, and terminates resultant ventricular tachycardia. Though it has some of the same fatty acid oxidation properties as TMZ, this is not considered its primary mechanism of action. This paper reviews medical approaches to chronic stable angina and highlights RNZ as an important advance for patients and clinicians in the US market.

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Enzyme Inhibitors; Humans; Piperazines; Ranolazine; Trimetazidine; Vasodilator Agents

According to current estimates, more than 12 million people in the United States have coronary artery disease (CAD). Slightly less than half experience angina pectoris, and more than 7 million have had a myocardial infarction. In 2000, the economic cost of CAD in this country totaled $118 billion. Given the aging of the population and the improved therapy for several other disorders, a true epidemic looms on the horizon. In this article, Dr Bales examines the long-term medical treatment of patients with known ischemic heart disease, focusing on therapies proven to alter morbidity and mortality, relieve symptoms, and modify risk factors.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Chronic Disease; Humans; Myocardial Ischemia; Platelet Aggregation Inhibitors; Risk Factors

Antianginal drugs that exert their anti-ischaemic effects primarily by altering myocardial metabolism have recently attracted attention. They have the potential to relieve symptoms in patients with refractory angina who are already on "optimal" medical therapy and have disease that is not amenable to revascularisation, making these drugs an attractive addition to therapy, particularly for the elderly population. In some cases, they may even be used as first-line treatment. These drugs increase glucose metabolism at the expense of free-fatty-acid metabolism, enhancing oxygen efficiency during myocardial ischaemia. Whilst they have been demonstrated to reduce ischaemia in several clinical trials, their use remains limited. This review aims to draw attention to these "metabolic" antianginal drugs while surveying the evidence supporting their use and mode of action. Four metabolic antianginal drugs are reviewed: perhexiline, trimetazidine, ranolazine, and etomoxir. We also discuss the metabolic actions of glucose-insulin-potassium and beta-blockers and describe myocardial metabolism during normal and ischaemic conditions. The potential of these metabolic agents may extend beyond the treatment of ischaemia secondary to coronary artery disease. They offer significant promise for the treatment of symptoms occurring due to inoperable aortic stenosis, hypertrophic cardiomyopathy, and chronic heart failure.

Topics: Acetanilides; Adrenergic beta-Antagonists; Angina Pectoris; Cardiovascular Agents; Drug Therapy, Combination; Enzyme Inhibitors; Epoxy Compounds; Glucose; Humans; Hypoglycemic Agents; Insulin; Myocardial Ischemia; Myocardium; Perhexiline; Piperazines; Potassium; Ranolazine; Trimetazidine

Patients with refractory angina are not candidates for revascularization and have both class III or IV angina and objective evidence of ischemia despite optimal medical therapy. An estimated 300,000 to 900,000 patients in the United States have refractory angina, and 25,000 to 75,000 new cases are diagnosed each year. This review focuses on treatment strategies for refractory angina and includes the mechanism of action and clinical trial data for each strategy. The pharmacological agents that have been used are ranolazine, ivabradine, nicorandil, L-arginine, testosterone, and estrogen; currently, only L-arginine, testosterone, and estrogen are approved by the Food and Drug Administration. Results with the noninvasive treatments of enhanced external counterpulsation and transcutaneous electrical nerve stimulation are provided. Invasive treatment strategies including spinal cord stimulation, transmyocardial revascularization, percutaneous myocardial revascularization, and gene therapy are also reviewed.

Topics: Angina Pectoris; Cardiovascular Agents; Counterpulsation; Electric Stimulation Therapy; Genetic Therapy; Humans; Myocardial Revascularization; Spinal Cord; Treatment Failure

A review on pathophysiology, pharmacotherapy and catheter based treatment of chronic stable angina has been given here with short details.

Topics: Angina Pectoris; Angioplasty; Cardiovascular Agents; Chronic Disease; Humans; Risk Factors; Stents

To prove the antianginal efficacy of drugs in patients with stable angina pectoris the notice of certain criteria is necessary for the planning and performance for the clinical investigation of medicinal products. They consist of the study design, the randomization, blinding, inclusion and exclusion criteria, definition of endpoints, the performance of the study, the doses and dosing scheme, the methods of investigation, the sample size estimation and the evaluation of the results. If there will be not paid enough attention to these criteria and conditions false positive but also false negative results can arise. The criteria necessary for proving the antianginal efficacy in patients with stable angina pectoris will be presented.

Topics: Angina Pectoris; Cardiovascular Agents; Dose-Response Relationship, Drug; False Positive Reactions; Humans; Randomized Controlled Trials as Topic; Research Design

Topics: Angina Pectoris; Cardiovascular Agents; Cocaine; Cocaine-Related Disorders; Diagnosis, Differential; Electrocardiography; Humans; Male; Middle Aged; Sympathomimetics; Vasoconstrictor Agents

Partial fatty acid oxidation inhibitors have raised great interest since they are expected to counteract a dysregulated gene expression of hypertrophied cardiocytes. Some of these compounds have been developed for treating non-insulin-dependent diabetes mellitus and stable angina pectoris. A shift from fatty acid oxidation to glucose oxidation leads to a reduced gluconeogenesis and improved economy of cardiac work. An increased glucose oxidation can be achieved with the following enzyme inhibitors: etomoxir, oxfenicine, methyl palmoxirate, S-15176, metoprolol, amiodarone, perhexiline (carnitine palmitoyltransferase-1); aminocarnitine, perhexiline (carnitine palmitoyltransferase-2); hydrazonopropionic acid (carnitine-acylcarnitine translocase); MET-88 (gamma-butyrobetaine hydroxylase); 4-bromocrotonic acid, trimetazidine, possibly ranolazine (thiolases); hypoglycin (butyryl-CoA dehydrogenase); dichloroacetate (pyruvate dehydrogenase kinase). CLINICAL TRIALS with trimetazidine and ranolazine showed that this shift in substrate oxidation has an antianginal action. Etomoxir and MET-88 improved the function of overloaded hearts by increasing the density of the Ca(2+) pump of sarcoplasmic reticulum (SERCA2). The promoters of SERCA2 and alpha-myosin heavy-chain exhibit sequences which are expected to respond to transcription factors responsive to glucose metabolites and/or peroxisome proliferator-responsive element (PPAR) agonists. Further progress in elucidating novel compounds which upregulate SERCA2 expression is closely linked to the characterization of regulatory sequences of the SERCA2 promoter.

Topics: Acetanilides; Angina Pectoris; Animals; Calcium; Cardiovascular Agents; Clinical Trials as Topic; Enzyme Inhibitors; Epoxy Compounds; Fatty Acids; Gene Expression; Glucose; Heart Failure; Humans; Hypoglycemic Agents; Methylhydrazines; Myocytes, Cardiac; Oxidation-Reduction; Piperazines; Ranolazine; Rats; Rats, Wistar; Sarcoplasmic Reticulum; Trimetazidine; Up-Regulation; Vasodilator Agents

Perhexiline was introduced about 30 years ago and rapidly gained a reputation for efficacy in the management of angina pectoris. However, hepatic and neurological adverse effects associated with perhexiline administration led to a marked decline in its use. The drug was originally classified as a coronary vasodilator, and later as a calcium channel antagonist, but recent data suggests that it acts as a cardiac metabolic agent, through inhibition of the enzyme, carnitine palmitoyltransferase-1 (CPT-1). Given the drug's unique anti-ischemic action and favorable hemodynamic profile, together with an improved understanding of the mechanisms underlying the adverse effects of the drug and the clear clinical need for additional therapies in refractory patients, perhexiline is currently being re-appraised as a potentially useful agent in the management of severe myocardial ischemia. Perhexiline is being considered for registration or re-registration in a number of countries and is being evaluated in a large-scale clinical trial in elderly patients with aortic stenosis and myocardial ischemia. This systematic review examines the evidence from available published literature in relation to the efficacy and tolerability of perhexiline in the treatment of cardiac disease. While there is a lack of well designed controlled trials using objective end-points to determine efficacy (almost all trials used a crossover design, included small numbers of patients and had limited statistical analysis of results), there is consistency in the data available that perhexiline is considerably more effective than placebo when used as monotherapy. Furthermore, it affords additional symptom relief in those already receiving maximal conventional anti-anginal therapy. However, there is a paucity of trials demonstrating the efficacy of low dosages of perhexiline (100 to 200 mg/day) in patients with refractory angina pectoris. Available evidence also suggests that the incidence of adverse events can be minimised, and the efficacy maintained, by keeping plasma perhexiline concentrations within a therapeutic range (150 to 600 micro g/L)

Topics: Angina Pectoris; Cardiovascular Agents; Dose-Response Relationship, Drug; Drug Interactions; Drug Therapy, Combination; Humans; Perhexiline; Product Surveillance, Postmarketing; Randomized Controlled Trials as Topic

Quantitative structure-activity relationships (QSARs) of various classes of antianginal drugs, e.g. nitrates, beta-adrenergic blocking agents (beta-blockers), and calcium channel blockers (calcium antagonists), have been reviewed. This review gives an overall picture of the mode of action of each class of drugs and points out the specific physicochemical and structural properties that govern their activity. It is observed that in almost all kinds of antianginal drugs the lipophilic factor plays an important role and the next important factor seems to be the steric ones. The electronic factors are found to be occasionally important. In the case of beta-blockers, the most common factor that appeared to govern the activity remained the lipophilicity. In nitrates, too, the activity is observed to primarily depend upon the lipophilicity. In calcium channel blockers, however, the dominant effect is seen to be of steric factors. The steric roles may be essential in drug-receptor interactions, which seem to involve both hydrophobic, and to a lesser extent, electronic interactions.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Humans; Structure-Activity Relationship

Topics: Angina Pectoris; Cardiovascular Agents; Free Radical Scavengers; Heart Diseases; Humans; Myocardial Infarction; Nitric Oxide; Nitric Oxide Donors

The provision of dental treatment under both local anaesthesia and sedation has an excellent safety record, although medical problems may occur. The high prevalence of cardiac disease in the population, particularly ischaemic heart disease, makes it the most common medical problem encountered in dental practice. Additionally, the increasing survival of children with congenital heart disease makes them a significant proportion of those attending for dental treatment. While most dental practitioners feel confident in performing cardio-pulmonary resuscitation, treating patients with co-existent cardio-vascular disease often causes concern over potential problems during treatment. This article aims to allay many of these fears by describing the commoner cardiac conditions and how they may affect dental treatment. It outlines prophylactic and remediable measures that may be taken to enable safe delivery of dental care.

Topics: Anesthesia, Dental; Angina Pectoris; Anticoagulants; Arrhythmias, Cardiac; Cardiovascular Agents; Dental Anxiety; Dental Care for Chronically Ill; Drug Interactions; Emergency Treatment; Endocarditis, Bacterial; Heart Defects, Congenital; Heart Diseases; Heart Valve Diseases; Humans; Hypertension; Monitoring, Intraoperative

This article studies the different methods of antianginal drug evaluation in the long-term treatment of ischemic heart disease. Subjective and objective methods are discussed with their limitations. The authors review serial ECG stress testing, this being the most frequently used method of antianginal pharmacotherapy evaluation. Safety, selected topics related to bioethics and statistical analysis in the clinical evaluation of drugs are discussed. Meta-analyses and clinical multicenter mega-trials, which are currently gaining in popularity and are likely to play an important role in the complex process of therapeutic decision making in the future, are discussed in the final section of this paper.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Electrocardiography; Exercise Test; Humans; Treatment Outcome

The treatment of stable angina should aim to relieve symptoms and in at-risk cases prolong life. Medical therapy, PTCA and CABG should be seen as complementary, not competitive, strategies. Optimal utilization of all three treatment modalities either alone or in combination can provide substantial and sustained symptomatic relief for angina patients. Metabolic agents such as Trimetazidine by acting at the cellular level and not influencing heart rate or blood pressure have a useful and unique role to play in addition to conventional haemodynamic agents such as the betablockers or calcium antagonists. This review looks at the role of trimetazidine as part of the overall management of the stable angina patient.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Humans; Prognosis; Randomized Controlled Trials as Topic

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Artery Bypass; Cost-Benefit Analysis; Health Care Rationing; Humans; Quality-Adjusted Life Years; Treatment Outcome

Under the reference-based pricing (RBP) policy, British Columbia will fund drug therapies based on the cost of the 'gold standard' therapy that meets the needs of the majority of patients with a specific condition. Hence, Pharmacare will pay for the lowest cost drug within a cluster of related but different drugs, regardless of the indication. When evaluating the impact of drugs on health care expenditure, one must consider that their costs are more than offset by the clinical and economic benefits they provide. Pharmaceutical expenditure accounts for a small proportion of health care expenditure and should be viewed as an essential and interactive component in the global health care budget rather than as an independent constituent. In that respect, insight should be gained from many countries in which RBP has been implemented A wealth of data converge to the same conclusion: price controls and restricted access to drugs do not reduce prescription drug expenditures but actually increase health care costs. Furthermore, cost containment being the main issue behind RBP in British Columbia, the contentious issue of therapeutic substitution has not been taken fully into consideration, nor has its impact on the quality of care of the patient. The case of diltiazem once-a-day versus diltiazem tablets for hypertensive and angina patients illustrates the important considerations that must be taken into account in writing the overall financial equation that drives the implementation of the RBP policy. If pharmacotherapy is to be an appropriate treatment to attain optimal cost effective health care, its benefit can only be optimized with a strategy that entails the right therapy, for the right patient, in the right dosage form and at the right time. Accordingly, RBP in British Columbia should be analyzed in light of patient welfare and appropriate use of collective resources.

Topics: Angina Pectoris; Antihypertensive Agents; British Columbia; Cardiovascular Agents; Cost Control; Diltiazem; Drug Administration Schedule; Drug Costs; Drugs, Generic; Humans; Hypertension; Patient Compliance; Prescription Fees; Quality of Health Care

One of the most difficult problems related to coronary artery disease is the detection and eventual treatment of silent myocardial ischemia (SMI). After defining the concept of SMI and total ischemia burden, the author approaches the pathophysiology of myocardial ischemia and focuses on the ischemic cascade. Concerning the detection of SMI the importance of exercise testing and Holter ECG is stressed. Following the classification of SMI proposed by P. F. Cohn, the author analyzes SMI type III with particular interest. He refers the prevalence of SMI in patients suffering from chronic stable angina, and focuses on the prognostic importance of SMI. Afterwards, the problem of treatment and prognostic implications is approached. The paper ends with mention of the results of the most important clinical trials in this field: CASIS, CAPE, TIBBS, ASIST, ACIP, TIBET.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Humans; Myocardial Ischemia; Prevalence; Prognosis

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Animals; Calcium Channel Blockers; Cardiovascular Agents; Chronic Disease; Heart Rate; Humans; Sinoatrial Node

Coronary artery disease is a major clinical problem in the elderly. This article discusses the medical management of stable and unstable angina pectoris. A review of the general measures and drug therapy used to treat these disorders, especially as they relate to the elderly patient are presented. In addition, new insights into the pathophysiologic mechanisms of chronic stable angina and unstable angina are reviewed.

Topics: Adrenergic beta-Antagonists; Aged; Angina Pectoris; Angina, Unstable; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Female; Humans; Male; Nitrates; Vasodilator Agents

Antianginal drug treatment reduces symptoms and ischemia but may also influence the prognosis of patients with stable angina pectoris. The Atenolol Silent Ischemia Study (ASIST) compared atenolol and placebo treatment (about 140 patient-years on each) in patients with mainly silent ischemia and found less aggravation of angina and a tendency toward fewer cardiac complications with atenolol treatment. The Total Ischaemic Burden European Trial (TIBET) compared slow release nifedipine, atenolol, or the combination (about 450 patient-years on each) and found no significant differences with regard to cardiac complications, a nonsignificant trend toward better prognosis on combined treatment, and more side effects on nifedipine alone compared with the other treatments. The Angina Prognosis Study in Stockholm (APSIS) compared metoprolol and verapamil (about 1,400 patient-years on each) and found similar effects on cardiovascular endpoints, tolerability, and psychosocial variables with the 2 treatments. Hypothesis-generating subgroup analyses in APSIS suggest that treatment effects may differ in hypertensive and diabetic subgroups. Beneficial effects in primary and secondary prevention, together with data from ASIST, suggest that beta 1 blockade influences prognosis favorably. The safety of short-acting nifedipine in ischemic heart disease is questioned, but TIBET data suggest that slow release nifedipine may be safe. Verapamil has beneficial effects after myocardial infarction (Danish Verapamil Infarction Trial II) and shows similar efficacy as metoprolol in the APSIS study. The paucity of placebo data (antianginal treatment cannot be withheld during long periods of time in symptomatic patients) precludes firm conclusions regarding effects of drug treatment on prognosis. It is argued that patients with stable angina pectoris do well on medical treatment, and that beta 1 blockers, verapamil, and, possibly, slow-release nifedipine may influence their prognosis favorably.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Female; Humans; Incidence; Male; Multicenter Studies as Topic; Prognosis

Angina pectoris and asymptomatic myocardial ischemia are part of the spectrum of coronary heart disease. Not the presence or absence of angina determines the future of the patient, but repeated ischemia and the progression of the coronaropathy. This progression is neither linear with time, nor is the moment of plaque rupture foreseeable. Silent myocardial infarctions increase with age and are very frequent in diabetics. In patients without neuropathy but with asymptomatic myocardial ischemia the central pain threshold is higher than in patients with angina pectoris. The best noninvasive test for the detection, localization and estimation of extension of myocardial ischemia, be it pain-free or symptomatic, is 201-thallium scintigraphy, combined with the exercise ECG. The fight against all amendable cardiovascular risk factors and pharmacotherapy are the first steps, if asymptomatic myocardial ischemia is suspected. Augmented dyspnea on effort and rhythm disturbances are indicators of advanced multivessel heart disease. Under these circumstances coronary angiography is indicated, and further treatment should follow the generally accepted rules such as for patients with angina pectoris.

Topics: Aging; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Diabetes Complications; Exercise Test; Humans; Myocardial Ischemia; Prognosis; Thallium Radioisotopes

The currently available antianginal drugs act by reduction of myocardial O2 requirement and/or by coronary vasodilatation. The choice between beta blockers, nitrates, calcium antagonists or their combination depends on the clinical presentation, coexisting disorders and specific factors in individual patients. In addition to symptomatic treatment, secondary prophylactic measures, such as aspirin and reduction of serum cholesterol, are also necessary to prevent progression of the underlying coronary artery disease. In this paper the comparative efficacy and the indications of the various types of antianginal drugs are discussed.

Topics: Angina Pectoris; Angina, Unstable; Calcium Channel Blockers; Cardiovascular Agents; Coronary Vasospasm; Humans; Isosorbide Dinitrate; Myocardial Infarction; Nitroglycerin; Platelet Aggregation Inhibitors; Vasodilator Agents

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Myocardial Infarction

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Myocardial Infarction

Topics: Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Humans; Myocardial Ischemia

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Humans; Isosorbide Dinitrate; Nitroglycerin; Vasodilator Agents

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Coronary Circulation; Electrocardiography; Humans; Myocardial Ischemia; Nitrates; Prognosis

The incidence of ischemic cardiac events is highest in the early morning hours (symptomatic and asymptomatic cardiac ischemia, myocardial infarction, and sudden death). Quantitatively, however, most of them occur during the rest of the day; therefore, an ideal therapy should be established in the early morning hours and be efficient all day long. We recommend that nitrates should be taken as early as possible after a dose-is-free interval during the night. Patients taking beta-blockers do not show a circadian rhythm of the incidence of ischemic cardiac events. Compliance can be improved with the never long-acting agents. Therapy should be tailored individually for each patient. It is not yet known whether calcium blockers influence the circadian rhythm. The efficacy of the never preparations is comparable to the older ones. Aspirin can be taken at any time of the day because of its long duration of action.

Topics: Angina Pectoris; Anticoagulants; Calcium Channel Blockers; Cardiovascular Agents; Circadian Rhythm; Coronary Disease; Humans; Platelet Aggregation Inhibitors

Chronopathology of cardiovascular disease is now well documented. Silent myocardial ischaemia involves the same pathophysiological changes as conventional ischaemia. Early morning peaks in angina and myocardial ischaemia call for adequate timing of medication. beta-blockers abolish the morning peak, and aspirin reduces morning infarctions. The effects of other antianginals on these phenomena are presently unknown.

Topics: Angina Pectoris; Blood Pressure; Cardiovascular Agents; Circadian Rhythm; Coronary Disease; Drug Administration Schedule; Heart Rate; Humans

Results are presented of surgical treatment of ischemic heart disease at the Kiev Research Institute of Cardiovascular Surgery in 1988-1989; 424 patients were operated on including 73 undergoing aneurysmectomy and valve prosthesis. The lethality was 6.1% improvement was observed in 96.7%; 78.3% were completely free of angina attacks. The tactics of medical and surgical treatment of ischemic heart disease are discussed.

Topics: Angina Pectoris; Cardiac Care Facilities; Cardiovascular Agents; Coronary Disease; Humans; Myocardium; Oxygen Consumption; Ukraine

The therapeutic goals for the patient with angina pectoris are to minimize the frequency and severity of angina and to improve functional capacity at a reasonable cost and with as few side effects as possible. An integrated approach necessitates attention to conditions that might be aggravating angina, such as anemia or hypertension. Alterations in life-style and personal habits, such as cessation of cigarette smoking, are often necessary and should be continually reinforced by the physician. Certain concomitant diseases, such as chronic obstructive pulmonary disease, may influence the selection of drug therapy. Nitrates, beta-adrenergic blockers, and calcium entry blockers are the major classes of drugs that can be used alone or in combination in a program that is designed for the individual patient.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Cardiovascular Diseases; Drug Interactions; Humans; Nitrates; Nitroglycerin

A rational therapy of angina pectoris has to consider two recent pathophysiologic insights: 1. Not only in patients with instable but also with stable angina a dynamic, vasospastic component in addition to stenosis plays an important role. Stable angina is often a mixed form of disease. 2. In many patients stable angina is complicated by silent ischemia. Therapy of stable angina has 3 goals: 1. prevention or alleviation of angina; 2. reduction of silent ischemia episodes (number, extent); 3. cardioprotection i.e. prevention of instable angina, infarction and sudden death. The pharmacotherapeutic cornerstones are the nitrates, beta-blocking agents and calcium channel blockers. Their generally equivalent efficacy in short and longterm use is clinically and hemodynamically proven without doubt. Mode of action, pharmacokinetic aspects and recent as well as controversial questions regarding this group of drugs are reviewed. The pharmacotherapy of first choice should be determined for each patient individually and not according to schematic prescription. It should encompass pathogenesis of ischemia, specific indications for or adverse effects of the 3 drug classes, the question of induction of tolerance, possible cardioprotective benefit, side effects, compliance problems and finally cost of treatment. The rational aspects of combination therapy (nitrates and beta-blockers, beta-blockers and calcium antagonists) are explained and the therapeutic procedures for instable angina are outlined.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Drug Therapy, Combination; Humans; Nitrates

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Coronary Disease; Energy Metabolism; Humans; Myocardium

Exercise trials in cardiology are often hindered by inconsistent approaches to exercise testing. These inconsistencies include the choice of exercise protocol, exercise end points, points of analysis, and absence or misuse of gas exchange data. Gas exchange techniques greatly enhance the accuracy with which cardiopulmonary function is assessed by exercise. Commonly used protocols are not always appropriate for all patients or all studies. Both cardiovascular disease and the exercise protocol can have an important impact on the relation between changes in work rate and oxygen uptake. Ramp protocols appear to offer the greatest promise for assessing cardiopulmonary function. Analyzing hemodynamic and gas exchange responses at several points submaximally, in addition to those at peak exercise, can add important information concerning the efficacy of a drug. A great deal of confusion continues to hinder the application of the gas exchange anaerobic threshold, and many of the commonly used testing end points are not reliable.

Topics: Anaerobic Threshold; Angina Pectoris; Cardiovascular Agents; Exercise Test; Humans; Pulmonary Gas Exchange; Reproducibility of Results

Like all other scientific disciplines, preclinical pharmacological research is subject to permanent changes. New measuring devices and the possibility of continuous on line data acquisition have markedly influenced basic research in this field. Another aim of modern cardiovascular pharmacology is the testing of promising drugs in clinically relevant animal models of disease, particularly under conditions, referring to the everyday situation in patients, e.g. physical activity. Investigations carried out in this way allow an exact assessment of the clinical efficacy of new drugs, and are, thus, clearly indispensable, also from the ethical point of view, before primary evaluation of the drug in man.

Topics: Angina Pectoris; Animals; Arrhythmias, Cardiac; Austria; Cardiovascular Agents; Cats; Dogs; Drug Evaluation, Preclinical; Electric Countershock; Humans; Hypertension; Myocardial Infarction; Pharmacology; Rats; Research

Topics: Adrenergic alpha-Agonists; Adrenergic beta-Antagonists; Angina Pectoris; Arrhythmias, Cardiac; Calcium Channel Blockers; Cardiovascular Agents; Digitalis; Diuretics; Hemodynamics; Humans; Hypertension; Isometric Contraction; Nitroglycerin; Physical Exertion; Plants, Medicinal; Plants, Toxic

Quality of life is impaired in patients with angina pectoris because of their symptoms, impaired activity, and anxiety. These various factors reduce enjoyment of life, but their components and interrelationships are difficult to measure in the individual. There is no consensus on the best methods of measurement of quality of life; many general instruments have been proposed but none that specifically concern angina pectoris. Despite the absence of such quantitative information, there is no doubt that antianginal drugs benefit the majority of patients and, despite their side effects, advantageously change the relationship between the factors that add up to "quality of life." How the relief of symptoms, both organic and psychologic, interact and how far they are offset by the negative aspects of treatment in the patient with angina pectoris remain to be defined. Past and present trials give encouragement that instruments will be developed that are relevant, valid, reproducible, and sufficiently sensitive to convincingly measure the different impacts on quality of life of the patient with angina pectoris.

Topics: Angina Pectoris; Attitude to Health; Cardiovascular Agents; Humans; Interview, Psychological; Psychological Tests; Psychology, Social; Quality of Life; Surveys and Questionnaires

Calcium channel blockers, nitrates, and beta blockers are the primary agents used for the treatment of angina. Calcium has a central role in excitation-contraction, action potential generation, and ischemic cell death. The three currently available calcium antagonists are nifedipine, verapamil, and diltiazem. Second-generation agents are in development, and a classification system of calcium channel blockers is used to place the currently available agents and those on the horizon in perspective. Nitrate pharmacology and pharmacodynamics are possibly related to nitrate tolerance; however, this is a matter of some controversy. The beta blockers are all equally effective in the treatment of angina; therefore, drug selection is based on ancillary properties.

Topics: Angina Pectoris; Cardiovascular Agents; Humans

The 3 main classes of antianginal drugs are nitrates, beta blockers, and calcium channel blockers. Nitrates have been viewed classically as affecting myocardial demand by reducing intraventricular volume and lowering the filling pressure of the left ventricle. They have been used increasingly to improve oxygen supply in myocardial ischemia by increasing coronary blood flow and actually causing coronary vasodilatation, and by having an effect on endothelial competence. Beta blockers are used to decrease myocardial blood flow by reducing myocardial demand, with reduction of myocardial contractility, afterload, and heart rate. No major improvement of oxygen supply is seen with this class of medication, and in fact, there is some potential for augmenting coronary vasoconstriction. Calcium channel blockers not only reduce myocardial demand by reducing afterload and, in some cases, heart rate, but similar to nitrates, they enhance myocardial oxygen supply.

Topics: Angina Pectoris; Cardiovascular Agents; Hemodynamics; Humans

An appreciation of the hemodynamic and biochemical changes induced by drugs is critical for a logical diagnostic interpretation of graded stress tests and the evaluation of the projected exercise prescription and exercise programs that a patient is asked to follow. Drug therapy is clearly not a contraindication to acute or chronic exercise as long as the potential benefits and complications of exercise and drug interaction are considered.

Topics: Angina Pectoris; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Hypertension; Physical Exertion

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Antihypertensive Agents; Cardiovascular Agents; Diuretics; Drug Therapy, Combination; Humans; Lipids; Lipoproteins; Propranolol

Diuretics are the mainstay of drug therapy in the treatment of many cardiovascular disorders. However, perusal of knowledge of their haemodynamic activities in heart failure and hypertension reveals major gaps. In left ventricular failure complicating acute myocardial infarction, intravenous frusemide reduces the elevated left heart filling pressure with little change in systemic blood pressure, heart rate or cardiac output, and restores the ability of the left heart to handle an acute increase in filling volume. But there is little knowledge of the haemodynamic effects of other intravenous diuretics, oral diuretics or diuretics other than those acting on the loop of Henle in this emergency clinical situation. Even less information is available on the haemodynamic effects of diuretics in patients in chronic heart failure. In patients with valvular heart disease, parenteral mercury and oral thiazides reduce right heart and pulmonary vascular pressures with variable (dose-dependent?) changes in cardiac output. Information on the effect of loop diuretics, the comparative effects of intravenous versus oral routes of administration and dose-response correlations are all lacking. In hypertension, the dose-blood pressure lowering response relationship of orally administered diuretics is relatively flat. The majority of information relates to oral thiazides; there is little reliable information on the anti-hypertensive efficacy of the loop diuretics. The acute and chronic effects of the majority of commonly used diuretics on cardiac and peripheral vascular functions is unexplained. More is known of their potentially adverse metabolic effects than of their possible circulatory benefits in hypertensive patients. Many unwanted side-effects of these drugs have been described; their potential importance is related directly to the disease state and doses in which they are used. In acute heart failure, their potential danger is probably minimal. In the treatment of chronic heart failure their most sinister potential is in the excessive secretion of potassium and magnesium. In hypertensive patients their long-term administration in high-doses may lead to undesirable metabolic effects that tend to offset their blood pressure lowering activity. Despite their drawbacks, diuretics continue to provide the natural first-line treatment of choice of these common cardiovascular syndromes. But more information on their mechanisms of vascular activities and the differences in non-d

Topics: Angina Pectoris; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Chronic Disease; Diuretics; Drug Interactions; Heart Failure; Humans; Hypertension; Kidney Diseases; Socioeconomic Factors

Topics: Angina Pectoris; Angina Pectoris, Variant; Cardiovascular Agents; Clinical Enzyme Tests; Coronary Angiography; Coronary Artery Bypass; Coronary Disease; Electrocardiography; Humans; Myocardial Infarction; Myocardial Revascularization; Prognosis

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Vessels; Drug Therapy; Hemodynamics; Humans; Nitrites; Pharmacology; Vasodilator Agents

Patients with refractory angina (RA) have poor quality of life and new therapies are needed. XC001 is a novel adenoviral vector expressing multiple isoforms of vascular endothelial growth factor (VEGF) promoting an enhanced local angiogenic effect.. The Epicardial Delivery of XC001 Gene Therapy for Refractory Angina Coronary Treatment (EXACT) trial is a 6-month (with 6-month extension) phase 1/2, first-in-human, multicenter, open-label, single-arm, dose-escalation study to evaluate the safety, tolerability, and preliminary efficacy of XC001 in patients with RA. The trial will enroll 33 patients in an initial (n = 12) ascending dose-escalation phase (1 × 10. The EXACT trial will determine whether direct intramyocardial administration of XC001 in patients with RA is safe and evaluate its effect on exercise tolerance, myocardial perfusion, angina and physical activity, informing future clinical investigation.. NCT04125732.

Topics: Adenoviridae; Aged; Angina Pectoris; Angiogenesis Inducing Agents; Cardiovascular Agents; Clinical Trials, Phase II as Topic; Drug Delivery Systems; Exercise Tolerance; Female; Genetic Therapy; Genetic Vectors; Humans; Male; Maximum Tolerated Dose; Pericardium; Treatment Outcome; Vascular Endothelial Growth Factors

The aim of this study was to test the hypothesis that invasive coronary function testing at time of angiography could help stratify management of angina patients without obstructive coronary artery disease.. Medical therapy for angina guided by invasive coronary vascular function testing holds promise, but the longer-term effects on quality of life and clinical events are unknown among patients without obstructive disease.. A total of 151 patients with angina with symptoms and/or signs of ischemia and no obstructive coronary artery disease were randomized to stratified medical therapy guided by an interventional diagnostic procedure versus standard care (control group with blinded interventional diagnostic procedure results). The interventional diagnostic procedure-facilitated diagnosis (microvascular angina, vasospastic angina, both, or neither) was linked to guideline-based management. Pre-specified endpoints included 1-year patient-reported outcome measures (Seattle Angina Questionnaire, quality of life [EQ-5D]) and major adverse cardiac events (all-cause mortality, myocardial infarction, unstable angina hospitalization or revascularization, heart failure hospitalization, and cerebrovascular event) at subsequent follow-up.. Between November 2016 and December 2017, 151 patients with ischemia and no obstructive coronary artery disease were randomized (n = 75 to the intervention group, n = 76 to the control group). At 1 year, overall angina (Seattle Angina Questionnaire summary score) improved in the intervention group by 27% (difference 13.6 units; 95% confidence interval: 7.3 to 19.9; p < 0.001). Quality of life (EQ-5D index) improved in the intervention group relative to the control group (mean difference 0.11 units [18%]; 95% confidence interval: 0.03 to 0.19; p = 0.010). After a median follow-up duration of 19 months (interquartile range: 16 to 22 months), major adverse cardiac events were similar between the groups, occurring in 9 subjects (12%) in the intervention group and 8 (11%) in the control group (p = 0.803).. Stratified medical therapy in patients with ischemia and no obstructive coronary artery disease leads to marked and sustained angina improvement and better quality of life at 1 year following invasive coronary angiography. (Coronary Microvascular Angina [CorMicA]; NCT03193294).

Topics: Aged; Angina Pectoris; Cardiac Catheterization; Cardiovascular Agents; Cause of Death; Clinical Decision-Making; Coronary Angiography; Disease Progression; Female; Fractional Flow Reserve, Myocardial; Humans; Male; Middle Aged; Patient Satisfaction; Predictive Value of Tests; Quality of Life; Recovery of Function; Scotland; Severity of Illness Index; Time Factors; Treatment Outcome

Chronic angina is more common in patients with diabetes mellitus (DM) with poor glucose control. Ranolazine both treats chronic angina and improves glucose control.. This study sought to examine ranolazine's antianginal effect in relation to glucose control.. The authors performed a secondary analysis of the RIVER-PCI (Ranolazine in Patients with Incomplete Revascularization after Percutaneous Coronary Intervention) trial, a clinical trial in which 2,604 patients with chronic angina and incomplete revascularization following percutaneous coronary intervention were randomized to ranolazine versus placebo. Mixed-effects models were used to compare the effects of ranolazine versus placebo on glycosylated hemoglobin (HbA. Overall, 961 patients (36.9%) had DM at baseline. Compared with placebo, ranolazine significantly decreased HbA. In patients with DM and chronic angina with incomplete revascularization after percutaneous coronary intervention, ranolazine's effect on glucose control and angina at 6 months was proportionate to baseline HbA

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Diabetes Complications; Female; Glycated Hemoglobin; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Ranolazine

Angina often persists or returns in populations following percutaneous coronary intervention (PCI). We hypothesized that ranolazine would be effective in reducing angina and improving quality of life (QOL) in incomplete revascularization (ICR) post-PCI patients.. In RIVER-PCI, 2604 patients with a history of chronic angina who had ICR post-PCI were randomized 1:1 to oral ranolazine versus placebo; QOL analyses included 2389 randomized subjects. Angina and QOL questionnaires were collected at baseline and months 1, 6, and 12. Ranolazine patients were more likely than placebo to discontinue study drug by month 6 (20.4% versus 14.1%, P<0.001) and 12 (27.2% versus 21.3%, P<0.001). Following qualifying index PCI, the primary QOL outcome (Seattle Angina Questionnaire [SAQ] angina frequency score) improved markedly, but similarly, in the ranolazine and placebo groups, respectively, from baseline (67.3±24.5 versus 69.7±24.0, P=0.01) to month 1 (86.6±18.1 versus 85.8±18.5, P=0.27) and month 12 (88.4±17.8 versus 88.5±17.8, P=0.94). SAQ angina frequency repeated measures did not differ in adjusted analysis between groups post baseline (mean difference 1.0; 95% CI -0.2, 2.2; P=0.11). Improvement in SAQ angina frequency was observed with ranolazine at month 6 among diabetics (mean difference 3.3; 95% CI 0.6, 6.1; P=0.02) and those with more angina (baseline SAQ angina frequency ≤60; mean difference 3.4; 95% CI 0.6, 6.2; P=0.02), but was not maintained at month 12.. Despite ICR following PCI, there was no incremental benefit in angina or QOL measures by adding ranolazine in this angiographically-identified population. These measures markedly improved within 1 month of PCI and persisted up to 1 year in both treatment arms.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01442038.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Double-Blind Method; Female; Humans; Male; Middle Aged; Myocardial Revascularization; Percutaneous Coronary Intervention; Quality of Life; Radiography; Ranolazine; Treatment Outcome

To explore the effect of ivabradine on angina-related quality of life (QoL) in patients participating in the Study Assessing the Morbidity-Mortality Benefits of the If Inhibitor Ivabradine in Patients with Coronary Artery Disease (SIGNIFY) QoL substudy.. QoL was evaluated in a prespecified subgroup of SIGNIFY patients with angina (Canadian Cardiovascular Society class score, ≥ 2 at baseline) using the Seattle Angina Questionnaire and a generic visual analogue scale on health status. Data were available for 4187 patients (2084 ivabradine and 2103 placebo). There were improvements in QoL in both treatment groups. The primary outcome of change in physical limitation score at 12 months was 4.56 points for ivabradine versus 3.40 points for placebo (E, 0.96; 95% confidence interval, -0.14 to 2.05; P=0.085). The ivabradine-placebo difference in physical limitation score was significant at 6 months (P=0.048). At 12 months, the visual analogue scale and the other Seattle Angina Questionnaire dimensions were higher among ivabradine-treated patients, notably angina frequency (P<0.001) and disease perception (P=0.006). Patients with the worst QoL at baseline (ie, those in the lowest tertile of score) had the best improvement in QoL for 12 months, with improvements in physical limitation and a significant reduction in angina frequency (P=0.034). The effect on QoL was maintained over the study duration, and ivabradine patients had better scores on angina frequency at every visit to 36 months.. Treatment with ivabradine did not affect the primary outcome of change in physical limitation score at 12 months. It did produce consistent improvements in other self-reported QoL parameters related to angina pectoris, notably in terms of angina frequency and disease perception.. URL: http://www.isrctn.com. Unique identifier: ISRCTN61576291.

Topics: Angina Pectoris; Benzazepines; Cardiovascular Agents; Coronary Artery Disease; Female; Humans; Ivabradine; Male; Middle Aged; Quality of Life; Surveys and Questionnaires; Visual Analog Scale

The objective of this study is to assess 3-year clinical outcome of patients with true bifurcation lesions (TBLs) versus non-true bifurcation lesions (non-TBLs) following treatment with second-generation drug-eluting stents (DES). TBLs are characterized by the obstruction of both main vessel and side-branch. Limited data are available on long-term clinical outcome following TBL treatment with newer-generation DES. We performed an explorative sub-study of the randomized TWENTE trial among 287 patients who had bifurcated target lesions with side-branches ≥2.0 mm. Patients were categorized into TBL (Medina classes: 1.1.1; 1.0.1; 0.1.1) versus non-TBL to compare long-term clinical outcome. A total of 116 (40.4 %) patients had TBL, while 171 (59.6 %) had non-TBL only. Target-lesion revascularization rates were similar (3.5 vs. 3.5 %; p = 1.0), and definite-or-probable stent thrombosis rates were low (both <1.0 %). The target-vessel myocardial infarction (MI) rate was 11.3 versus 5.3 % (p = 0.06), mostly driven by (periprocedural) MI ≤48 h from PCI. All-cause mortality and cardiac death rates were 8.7 versus 3.5 % (p = 0.06) and 3.5 versus 1.2 % (p = 0.22), respectively. The 3-year major adverse cardiac event rate for patients with TBL versus non-TBL was 20.0 versus 11.7 % (p = 0.05). At 1-, 2-, and 3-year follow-up, 6.5, 13.0, and 11.0 % of patients reported chest pain at less than or equal moderate physical effort, respectively, without any between-group difference. Patients treated with second-generation DES for TBL had somewhat higher adverse event rates than patients with non-TBL, but dissimilarities did not reach statistical significance. Up to 3-year follow-up, the vast majority of patients of both groups remained free from chest pain.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Thrombosis; Disease-Free Survival; Drug-Eluting Stents; Everolimus; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Prosthesis Design; Risk Factors; Sirolimus; Time Factors; Treatment Outcome

This paper aims to study the effect of Shengjie Tongyu granules on the treatment of meteorological cardiovascular disease in clinical treatment. Tongxinluo capsule that is clinically recognized as the effective drug in treating coronary heart disease and angina and was adopted as positive control. The results showed that, angina score and TCM score of two groups were all significantly improved after the treatment (P<0.01), but there was no statistical significance in comparison between groups (P>0.05); total effective rate of angina in the treatment group (77.78%) was superior than the control group (62.52%) after the treatment; but the difference had no statistical significance (P>0.05); total effective rate of TCM syndrome in the treatment group (75%) was superior than the control group (58.62%), and the difference had statistical significance (P<0.05). All these findings suggested that, Shengjie Tongyu granules can effectively improve the clinical symptoms of patients with coronary heart disease and angina, with the curative effect similar to Tongxinluo capsule; meanwhile, it can increase HDL-C and improve abnormal lipid metabolism of angina patient. In the treatment process, there is no significant untoward effect, blood, routine urine test and hepatorenal function have no abnormality, which proves that this drug is safe.

Topics: Aged; Angina Pectoris; Biomarkers; Cardiovascular Agents; China; Cholesterol, HDL; Coronary Disease; Drugs, Chinese Herbal; Female; Humans; Male; Meteorological Concepts; Middle Aged; Treatment Outcome; Up-Regulation

This study assessed clinical events and patient-reported chest pain 2 years after treatment of all-comers with Resolute Integrity zotarolimus-eluting stents (Medtronic Vascular, Santa Rosa, California) and Promus Element everolimus-eluting stents (Boston Scientific, Natick, Massachusetts).. For both drug-eluting stents (DES), no all-comer outcome data from >12 months of follow-up have been published. Although there is increasing interest in patient-reported chest pain following stenting, data with novel DES are scarce.. The DUTCH PEERS multicenter trial (TWENTE II) (DUrable Polymer-Based STent CHallenge of Promus ElemEnt Versus ReSolute Integrity) Randomized Trial [TWENTE II]) randomized 1,811 all-comer patients to treatment with 1 type of DES. Monitoring and event adjudication were performed by independent contract research organizations.. The 2-year follow-up of 1,810 patients (99.9%) was available. The primary composite endpoint target vessel failure occurred in 8.6% and 7.8% of patients treated with zotarolimus- and everolimus-eluting stents, respectively (p = 0.55). Rates of components of target vessel failure were: cardiac death (2.4% vs. 1.9%, p = 0.42); target vessel-related myocardial infarction (2.4% vs. 1.8%, p = 0.33); clinically-indicated target vessel revascularization (4.6% vs. 4.9%, p = 0.83). At 1- and 2-year follow-up, >80% of patients were free from chest pain (no between-stent difference). In addition, >87% of patients were either free from chest pain or experienced pain only at maximal physical exertion, but not during normal daily activities. Patients with chest pain after 12 months at no more than moderate physical effort had a higher risk of target vessel revascularization during the following year (hazard ratio: 1.89 [95% confidence interval: 1.05 to 3.39], p = 0.03).. During the second year of follow-up, the incidence of adverse clinical endpoints remained similar and low for both DES. The vast majority of patients were free from chest pain.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Drug-Eluting Stents; Everolimus; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Polymers; Proportional Hazards Models; Prospective Studies; Prosthesis Design; Risk Factors; Single-Blind Method; Sirolimus; Time Factors; Treatment Outcome

Ranolazine and metformin may be frequently co-administered in subjects with chronic angina and co-morbid type 2 diabetes mellitus (T2DM). The potential for a drug-drug interaction was explored in two phase 1 clinical studies in subjects with T2DM to evaluate the pharmacokinetics and safety of metformin 1000 mg BID when administered with ranolazine 1000 mg BID (Study 1, N = 28) or ranolazine 500 mg BID (Study 2, N = 25) as compared to metformin alone. Co-administration of ranolazine 1000 mg BID with metformin 1000 mg BID resulted in 1.53- and 1.79-fold increases in steady-state metformin Cmax and AUCtau , respectively; co-administration of ranolazine 500 mg BID with metformin 1000 mg BID resulted in 1.22- and 1.37-fold increases in steady-state metformin Cmax and AUCtau , respectively. Co-administration of ranolazine and metformin was well tolerated in these T2DM subjects, with no serious adverse events or drug-related adverse events leading to discontinuation. The most common adverse events were nausea, diarrhea, and dizziness. These findings are consistent with a dose-related interaction between ranolazine and metformin, and suggest that a dose adjustment of metformin may not be required with ranolazine 500 mg BID; whereas, the metformin dose should not exceed 1700 mg of total daily dose when using ranolazine 1000 mg BID.

Topics: Adult; Aged; Angina Pectoris; Animals; Area Under Curve; Cardiovascular Agents; CHO Cells; Chronic Disease; Comorbidity; Cricetulus; Diabetes Mellitus, Type 2; Double-Blind Method; Drug Interactions; Female; Humans; Hypoglycemic Agents; Male; Metabolic Clearance Rate; Metformin; Middle Aged; Organic Cation Transporter 2; Polypharmacy; Ranolazine; United States

The practice of traditional Chinese medicine (TCM) has a profound history in many Asian countries. TCM syndrome is a set of characteristic physical signs and symptoms shared by a group of patients. Syndrome diagnosis and treatment assignment according to the identified TCM syndrome is a long-held practice of Chinese medicine. Owing to its distinctive way of interpreting illness and administering care, medical practitioners not well educated in TCM theories and practices are generally incapable of giving out prescriptions for Chinese patent drugs. Currently, the existence of a multitude of Chinese patent drugs marked with largely identical indications is further complicating this situation.. In this multicenter, randomized, controlled, double-blind, double-dummy clinical trial, in which we will use the comparative effectiveness research method, we will compare the efficacy of two commonly used Chinese patent medicines for angina patients diagnosed with qi deficiency and blood stasis syndrome. A total of 160 patients will be recruited and randomly assigned to receive either (1) QiShenYiQi dripping pills, Tongxinluo placebo and routine medication or (2) Tongxinluo capsules, QiShenYiQi placebo and routine medication. These treatment regimens will be carried out for 4 weeks, followed by a 10-day washout period and a 4-week crossover phase in which the treatments in the two patient groups will be exchanged. Patients will be allowed to choose symptoms that matter most to them and will be grouped accordingly. Patient-reported outcomes such as the Seattle Angina Questionnaire score and the 15-point Likert scale score will be measured and reported. The minimally clinical important difference will be calculated and used for efficacy assessment, and correspondence analysis will be performed to identify the best indications for each drug.. The goal of the study is to establish a methodology for the precise identification of the characteristic indications for which a Chinese patent drug is most effective. The findings of this study will inform the practicality of the proposed evaluation method.. Chinese clinical trials register Chi CTRTTRCC13003732.

Topics: Administration, Oral; Adult; Aged; Angina Pectoris; Capsules; Cardiovascular Agents; China; Clinical Protocols; Comparative Effectiveness Research; Coronary Disease; Cross-Over Studies; Double-Blind Method; Drugs, Chinese Herbal; Female; Humans; Male; Middle Aged; Research Design; Surveys and Questionnaires; Tablets; Time Factors; Treatment Outcome

Ischaemia in different arterial territories before acute myocardial infarction (AMI) may influence post-AMI outcomes. No studies have evaluated prospectively collected information on ischaemia and its effect on short- and long-term coronary mortality. The objective of this study was to compare patients with and without prospectively measured ischaemic presentations before AMI in terms of infarct characteristics and coronary mortality.. As part of the CALIBER programme, we linked data from primary care, hospital admissions, the national acute coronary syndrome registry and cause-specific mortality to identify patients with first AMI (n = 16,439). We analysed time from AMI to coronary mortality (n = 5283 deaths) using Cox regression (median 2.6 years follow-up), comparing patients with and without recent ischaemic presentations. Patients with ischaemic presentations in the 90 days before AMI experienced lower coronary mortality in the first 7 days after AMI compared with those with no prior ischaemic presentations, after adjusting for age, sex, smoking, diabetes, blood pressure and cardiovascular medications [HR: 0.64 (95% CI: 0.57-0.73) P < 0.001], but subsequent mortality was higher [HR: 1.42 (1.13-1.77) P = 0.001]. Patients with ischaemic presentations closer in time to AMI had the lowest seven day mortality (P-trend = 0.001).. In the first large prospective study of ischaemic presentations prior to AMI, we have shown that those occurring closest to AMI are associated with lower short-term coronary mortality following AMI, which could represent a natural ischaemic preconditioning effect, observed in a clinical setting.. Clinicaltrials.gov identifier NCT01604486.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Atherosclerosis; Cardiovascular Agents; Cerebrovascular Disorders; Electronic Health Records; Female; Follow-Up Studies; Humans; Ischemia; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Peripheral Arterial Disease; Prognosis; Prospective Studies; Risk Factors

Coronary artery disease is the leading cause of death in women. The proposed treatments for women are similar to those for men. However, in women with multivessel stable coronary artery disease and normal left ventricular function, the best treatment is unknown.. A post hoc analysis of the MASS II study with 10 years of follow-up, mean (standard deviation) 6.8 (3.7) years, enrolled between May 1995 and May 2000, evaluated 188 women with chronic stable multivessel coronary artery disease who underwent medical treatment, percutaneous coronary intervention or coronary artery bypass graft surgery. Primary end-points were incidence of total mortality, Q-wave myocardial infarction, or refractory angina. Data were analysed according to the intention-to-treat principle.. Women treated with percutaneous coronary intervention and medical treatment had more primary events than those treated with coronary artery bypass graft surgery, respectively, of 34, 44 and 22% (P = 0.003). Survival rates at 10 years were 72% for coronary artery bypass graft surgery, 72% for percutaneous coronary intervention and 56% for medical treatment (P = 0.156). For the composite end-point, Cox regression analysis adjusted for age, diabetes, hypertension, treatment allocation, prior myocardial infarction, smoking, number of vessels affected and total cholesterol, had a higher incidence of primary events with medical treatment than with coronary artery bypass graft surgery [hazard ratio (HR) = 2.38 (95% confidence interval (CI): 1.40-4.05); P = 0.001], a lower incidence with percutaneous coronary intervention than with medical treatment [HR = 0.60 (95% CI: 0.38-0.95); P = 0.031] but no differences between coronary artery bypass graft surgery and percutaneous coronary intervention. Regarding death, a protective effect was observed with percutaneous coronary intervention compared with medical treatment [HR = 0.44 (95% CI: 0.21-0.90); P = 0.025].. Percutaneous coronary intervention and coronary artery bypass graft surgery compared with medical treatment had better results after 10 years of follow-up.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Chi-Square Distribution; Chronic Disease; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Kaplan-Meier Estimate; Middle Aged; Multivariate Analysis; Myocardial Infarction; Percutaneous Coronary Intervention; Proportional Hazards Models; Risk Factors; Sex Factors; Survival Rate; Time Factors; Treatment Outcome; Ventricular Function, Left

This study sought to assess the impact of coronary bifurcation stenting on health-related functional status, using the Seattle Angina Questionnaire (SAQ), for participants in the BBC ONE (British Bifurcation Coronary; Old, New, and Evolving Strategies) trial and to compare simple versus complex bifurcation stenting strategies in this regard.. Large randomized studies have examined outcomes from bifurcation stenting with drug-eluting stents. They have reported on major adverse cardiovascular events and angiographic follow-up. However, a principal goal of percutaneous coronary intervention is symptom control and improvement in quality of life, yet there are no published data from these trials on this aspect. Furthermore, it is unknown whether simple versus complex stenting strategies have different effects on angina control and quality of life.. The BBC ONE study randomized 500 subjects to bifurcation stenting using either a simple (provisional T) or complex (crush or culotte) approach. Subjects completed the SAQ at baseline and at 9 months after percutaneous coronary intervention. Canadian Cardiovascular Society class and antianginal drug use were also evaluated.. Bifurcation stenting was associated with significant improvements on SAQ scales and in Canadian Cardiovascular Society class (baseline: 5.3% subjects were class 0; follow-up: 64.0% were class 0; p < 0.001) and a significant reduction in the number of antianginal drugs used (median decrease: 1; p < 0.001). Simple and complex strategies did not differ significantly for changes in the SAQ, actual SAQ scores, or use of antianginal drugs.. Regardless of chosen strategy, bifurcation stenting produced significant functional improvements in angina-related health. No significant difference between simple and complex strategies was found in this regard.

Topics: Angina Pectoris; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Disease; Drug-Eluting Stents; Health Status; Humans; Patient Satisfaction; Percutaneous Coronary Intervention; Prospective Studies; Quality of Life; Surveys and Questionnaires; Time Factors; Treatment Outcome; United Kingdom

The RASCAL (Refractory Angina Spinal Cord stimulation and usuAL care) pilot study seeks to assess the feasibility of a definitive trial to assess if addition of spinal cord stimulation (SCS) to usual care is clinically superior and more cost-effective than usual care alone in patients with refractory angina.. This is an external pilot, patient-randomized controlled trial.The study will take place at three centers in the United Kingdom - South Tees Hospitals NHS Foundation Trust (The James Cook University Hospital), Dudley Group of Hospitals NHS Foundation Trust, and Basildon and Thurrock University Hospitals NHS Foundation Trust.The subjects will be 45 adults with refractory angina, that is, limiting angina despite optimal anti-angina therapy, Canadian Cardiovascular Society Functional Classification Class III and IV, angiographically documented coronary artery disease not suitable for revascularization, satisfactory multidisciplinary assessment and demonstrable ischemia on functional testing.The study will be stratified by center, age and Canadian Cardiovascular Society Functional Classification.Interventions will involve spinal cord stimulation plus usual care ('SCS group') or usual care alone ('UC group'). Usual care received by both groups will include consideration of an education session with a pain consultant, trial of a transcutaneous electrical neurostimulation, serial thoracic sympathectomy and oral/systemic analgesics.Expected outcomes will be recruitment and retention rates; reasons for agreeing/declining participation; variability in primary and secondary outcomes (to inform power calculations for a definitive trial); and completion rates of outcome measures. Trial patient-related outcomes include disease-specific and generic health-related quality of life, angina exercise capacity, intake of angina medications, frequency of angina attacks, complications and adverse events, and satisfaction.. The RASCAL pilot trial seeks to determine the feasibility and design of a definitive randomized controlled trial comparing the addition of spinal cord stimulation to usual care versus usual care alone for patients with refractory angina.Fifteen patients have been recruited since recruitment opened in October 2011. The trial was originally scheduled to end in April 2013 but due to slow recruitment may have to be extended to late 2013.. ISRCTN65254102.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Protocols; Cost-Benefit Analysis; Drug Resistance; England; Feasibility Studies; Health Care Costs; Humans; Patient Satisfaction; Pilot Projects; Research Design; Spinal Cord Stimulation; Time Factors; Treatment Outcome

This study evaluated differences in outcome among women and men enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial.. Women and men with coronary artery disease have different clinical presentations and outcomes that might be due to differences in management.. We compared baseline variables, study interventions, and outcomes between women and men enrolled in the BARI 2D trial and randomized to aggressive medical therapy alone or aggressive medical therapy with prompt revascularization.. At enrollment, women were more likely than men to have angina (67% vs. 58%, p < 0.01) despite less disease on angiography (Myocardial Jeopardy Index 41 ± 24 vs. 46 ± 24, p < 0.01; number of significant lesions 2.3 ± 1.7 vs. 2.8 ± 1.8, p < 0.01). Over 5 years, no sex differences were observed in BARI 2D study outcomes after adjustment for difference in baseline variables (death/myocardial infarction/cerebrovascular accident: hazard ratio: 1.11, 99% confidence interval [CI]: 0.85 to 1.44). However, women reported more angina than men (adjusted odds ratio: 1.51, 99% CI: 1.21 to 1.89, p < 0.0001) and had lower scores for the Duke Activity Status Index (adjusted beta coefficient: -1.58, 99% CI: -2.84 to -0.32, p < 0.01).. There were no sex differences in death, myocardial infarction, or cerebrovascular accident among patients enrolled in the BARI 2D trial. However, compared with men, women had more symptoms and less anatomic disease at baseline, with persistence of higher angina rates and lower DASI scores after 5 years of medical therapy with or without prompt revascularization. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).

Topics: Adrenergic beta-Antagonists; Adult; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Diabetes Complications; Diabetes Mellitus, Type 2; Diet; Diuretics; Exercise; Female; Follow-Up Studies; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Kaplan-Meier Estimate; Male; Middle Aged; Platelet Aggregation Inhibitors; Prevalence; Quality of Life; Risk Reduction Behavior; Severity of Illness Index; Sex Distribution; Sex Factors; Smoking Cessation; Social Support; Treatment Outcome

This paper is a report of a qualitative study conducted as part of a randomized controlled trial comparing a lay-facilitated angina management programme with usual care. Its aim was to explore participants' beliefs, experiences, and attitudes to the care they had received during the trial, particularly those who had received the angina management intervention.. Angina affects over 50 million people worldwide. Over half of these people have symptoms that restrict their daily life and would benefit from knowing how to manage their condition.. A nested qualitative study within a randomized controlled trial of lay-facilitated angina management.. We conducted four participant focus groups during 2008; three were with people randomized to the intervention and one with those randomized to control. We recruited a total of 14 participants to the focus groups, 10 intervention, and 4 control.. Although recruitment to the focus groups was relatively low by comparison to conventional standards, each generated lively discussions and a rich data set. Data analysis demonstrated both similarities and differences between control and intervention groups. Similarities included low levels of prior knowledge about angina, whereas differences included a perception among intervention participants that lifestyle changes were more easily facilitated with the help and support of a lay-worker.. Lay facilitation with the Angina Plan is perceived by the participants to be beneficial in supporting self-management. However, clinical expertise is still required to meet the more complex information and care needs of people with stable angina.

Topics: Angina Pectoris; Cardiovascular Agents; Focus Groups; Humans; Life Style

Patients with multivessel coronary disease treated with coronary artery bypass graft (CABG) have less angina than those treated with percutaneous coronary intervention (PCI); however, there is uncertainty as to the mechanism of greater angina relief with CABG and whether more frequent repeat revascularization in patients treated with PCI could account for this treatment difference.. In the Synergy between percutaneous coronary intervention (PCI) with TAXUS and Cardiac Surgery trial, 1800 patients with 3-vessel or left main coronary artery disease were randomized to CABG or PCI with paclitaxel-eluting stents. Health status was assessed at baseline, 1, 6, and 12 months, using the Seattle Angina Questionnaire and the Medical Outcomes Study Short Form General Health Survey, and the association between repeat revascularization and health status during follow-up was assessed using longitudinal models. In adjusted analyses, patients who underwent repeat revascularization had worse angina frequency scores than patients who did not in both treatment groups, with differences of 8.5 points at 6 months and 3.1 points at 12 months in patients treated with PCI and 19.8 points at 6 months and 11.2 points at 12 months in patients with patients treated with CABG. Among patients who did not require repeat revascularization, the adjusted effect of CABG versus PCI on 12-month angina frequency scores was nearly identical to the overall benefit in the intention-to-treat analysis.. Among patients with multivessel coronary artery disease treated with PCI or CABG, the occurrence of repeat revascularization during follow-up did not fully explain the antianginal benefit of CABG in the overall population. The differential association between repeat revascularization and anginal status, according to the type of initial revascularization procedure, suggests that this end point should play a limited role in any direct comparison of the 2 treatment strategies.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Bypass; Coronary Artery Disease; Drug-Eluting Stents; Female; Health Status; Humans; Male; Middle Aged; Paclitaxel; Patient Satisfaction; Prosthesis Design; Quality of Life; Reoperation; Retreatment; Risk Assessment; Risk Factors; Surveys and Questionnaires; Time Factors; Treatment Outcome

The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial compared percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) to OMT alone in reducing the risk of cardiovascular events in 2287 patients with stable coronary disease. We examined the cost-effectiveness of PCI as a function of angina severity at the time of randomization.. Angina severity was assessed with the Seattle Angina Questionnaire (SAQ). Patients were grouped into tertiles based on the distribution of baseline scores such that higher tertiles represented better health status. Clinically significant improvement from baseline within individual patients was defined as score increases of >8 for physical limitation, >20 for angina frequency, and >16 for quality-of-life domains. The incremental cost-effectiveness ratio for PCI was calculated as the difference in costs divided by the difference in proportion of patients with clinically significant improvement. Improvement in angina severity was significantly greater for PCI patients in the lowest and middle tertiles. The number of patients needed to treat was much larger for the highest tertile. The added in-trial cost of PCI ranged from $7300 to $13 000. Incremental cost-effectiveness ratios ranged from $80 000 to $330 000 for the lowest and middle tertiles and from $520 000 to >$3 million for the highest tertile for 1 additional patient to achieve significant clinical improvement in health status.. The incremental cost of PCI to provide meaningful clinical benefit above that achieved by OMT alone was lower for patients with severe angina than for those with mild or no angina. However, it is uncertain that at any level of angina severity that PCI as an initial strategy would achieve a socially acceptable cost threshold. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00007657.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Cost-Benefit Analysis; Endpoint Determination; Female; Follow-Up Studies; Health Status; Humans; Male; Middle Aged; Retrospective Studies; Severity of Illness Index; Treatment Outcome

We assessed the independent effects of beta blockers, calcium antagonists, lipid-lowering drugs, angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), anti-platelet drugs, vitamin K antagonists, percutaneous coronary intervention (PCI) and coronary artery by-pass grafting (CABG) on mortality and on the composite endpoint of death, myocardial infarction, stroke or heart failure in patients with stable angina pectoris. We estimated the effects of the interventions used at baseline by multivariate Cox regression and during follow-up by G-estimation in 7,665 patients followed for a mean of 5 years in the ACTION trial. Adjusted hazard ratios (95% confidence intervals) comparing all cause mortality among users during follow-up to non-users were 1.01 (0.91, 1.09) for beta blockade, 0.82 (0.75, 0.89) for ACEIs or ARBs, 0.93 (0.87, 0.98) for calcium antagonists, 0.54 (0.49, 0.62) for lipid-lowering drugs, 0.49 (0.42, 0.53) for anti-platelet drugs, 0.74 (0.69, 0.78) for PCI, and 0.91 (0.82, 0.98) for CABG. Effects on the composite endpoint were less marked. This observational study confirms that ACEIs or ARBs, lipid-lowering and anti-platelet drugs as used in the everyday management of stable angina have independent secondary preventive effects. Calcium antagonists, PCI and CABG also appear to improve outcome.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Cause of Death; Coronary Artery Bypass; Coronary Disease; Female; Humans; Hypolipidemic Agents; Male; Middle Aged; Proportional Hazards Models; Secondary Prevention; Treatment Outcome

A growing number of patients with coronary disease have refractory angina. Preclinical and early-phase clinical data suggest that intramyocardial injection of autologous CD34+ cells can improve myocardial perfusion and function.. Evaluate the safety and bioactivity of intramyocardial injections of autologous CD34+ cells in patients with refractory angina who have exhausted all other treatment options.. In this prospective, double-blind, randomized, phase II study (ClinicalTrials.gov identifier: NCT00300053), 167 patients with refractory angina received 1 of 2 doses (1×10(5) or 5×10(5) cells/kg) of mobilized autologous CD34+ cells or an equal volume of diluent (placebo). Treatment was distributed into 10 sites of ischemic, viable myocardium with a NOGA mapping injection catheter. The primary outcome measure was weekly angina frequency 6 months after treatment. Weekly angina frequency was significantly lower in the low-dose group than in placebo-treated patients at both 6 months (6.8±1.1 versus 10.9±1.2, P=0.020) and 12 months (6.3±1.2 versus 11.0±1.2, P=0.035); measurements in the high-dose group were also lower, but not significantly. Similarly, improvement in exercise tolerance was significantly greater in low-dose patients than in placebo-treated patients (6 months: 139±151 versus 69±122 seconds, P=0.014; 12 months: 140±171 versus 58±146 seconds, P=0.017) and greater, but not significantly, in the high-dose group. During cell mobilization and collection, 4.6% of patients had cardiac enzyme elevations consistent with non-ST segment elevation myocardial infarction. Mortality at 12 months was 5.4% in the placebo-treatment group with no deaths among cell-treated patients.. Patients with refractory angina who received intramyocardial injections of autologous CD34+ cells (10(5) cells/kg) experienced significant improvements in angina frequency and exercise tolerance. The cell-mobilization and -collection procedures were associated with cardiac enzyme elevations, which will be addressed in future studies.

Topics: Aged; Angina Pectoris; Antigens, CD34; Biomarkers; Blood Component Removal; Cardiovascular Agents; Coronary Circulation; Double-Blind Method; Endothelial Cells; Exercise Test; Exercise Tolerance; Female; Hematopoietic Stem Cell Mobilization; Hematopoietic Stem Cell Transplantation; Humans; Least-Squares Analysis; Male; Microcirculation; Middle Aged; Myocardial Ischemia; Myocardium; Neovascularization, Physiologic; Prospective Studies; Regeneration; Regression Analysis; Risk Assessment; Risk Factors; Surveys and Questionnaires; Time Factors; Tomography, Emission-Computed, Single-Photon; Transplantation, Autologous; Treatment Outcome; United States

Prostaglandin E1 incorporated into lipid microspheres (lipo-PGE1) is effective in the treatment of peripheral vascular disorders and diabetic neuropathy. It is unknown whether it has protective effects in patients with angina pectoris undergoing percutaneous coronary intervention (PCI).. The goal of this pilot study was to investigate whether lipo-PGE1 has protective effects in patients with angina pectoris undergoing PCI.. A single-blinded, randomized controlled trial was conducted in 79 patients with stable or unstable angina pectoris. The control group received standard medical therapy, and the Lipo-PGE1 group (n = 40) received 20 μg/day of lipo-PGE1 intravenously, starting at least 48 h before PCI and continuing for 5 days. Cardiac troponin T (cTnT) and creatine kinase myocardial isoenzyme (CK-MB) were measured before lipo-PGE1 infusion and at 6, 12 and 24 h after PCI.. The cTnT and CK-MB concentrations were lower in the lipo-PGE1 group than in the control group at 6 h (0.15 ± 0.33 vs. 0.43 ± 0.77; 2.87 ± 3.99 vs. 5.64 ± 6.27, respectively; P < 0.05), 12 h (0.20 ± 0.48 vs. 0.54 ± 0.85; 3.58 ± 5.22 vs. 7.45 ± 9.48; P <  0.05) and 24 h (0.18 ± 0.50 vs. 0.50 ± 0.75; 3.15 ± 4.50 vs. 6.16 ± 6.83; P < 0.05). The incidence of postprocedural myocardial injury, defined as an elevation of cTnT more than 0.1 ng/ml or CK-MB more than 5.0 ng/ml, was less in the PGE1 group than in the control group (30 vs. 54%; 13 vs. 31%, respectively; P < 0.05). Lipo-PGE1 was well tolerated and there were no serious adverse events or side-effects.. Lipo-PGE1 treatment appears to reduce myocardial injury following elective PCI in angina patients.

Topics: Aged; Alprostadil; Analysis of Variance; Angina Pectoris; Angina, Unstable; Angioplasty, Balloon, Coronary; Biomarkers; Cardiovascular Agents; Chi-Square Distribution; China; Coronary Angiography; Creatine Kinase, MB Form; Drug Administration Schedule; Female; Heart Diseases; Humans; Infusions, Intravenous; Liposomes; Male; Microspheres; Middle Aged; Pilot Projects; Single-Blind Method; Time Factors; Treatment Outcome; Troponin T

To define the safety, informative value, and performance conditions of exercise echocardiography (EchoCG) in patients with stable angina (SA) concurrent with chronic obstructive pulmonary disease (COPD).. Forty patients aged 45 to 66 years (mean age 54.8 +/- 4.9 years) with Functional Class (FC) II-III SA concurrent with COPD and 40 patients aged 46 to 65 years (mean 56.6 +/- 4.9 years) with FC II-III SA without COPD were examined. All the patients underwent exercise EchoCG during the chosen therapy.. Exercise EchoCG is safe in patients with SA with COPD. To enhance the informative value of this test and to achieve the ischemic threshold in patients of this category require the use of adequate bronchodilator therapy. In this case, the informative value of the technique is 75%.. Exercise EchoCG in patients with SA concurrent with COPD may serve as a reliable tool in determining exercise endurance during antianginal, bronchodilator therapy and in assessing its adequacy.

Topics: Aged; Angina Pectoris; Bronchodilator Agents; Cardiovascular Agents; Echocardiography, Stress; Electrocardiography, Ambulatory; Exercise Test; Female; Heart Rate; Humans; Lung Diseases, Obstructive; Male; Middle Aged; Predictive Value of Tests; Sensitivity and Specificity

Experimental evidence suggests that xanthine oxidase inhibitors can reduce myocardial oxygen consumption for a particular stroke volume. If such an effect also occurs in man, this class of inhibitors could become a new treatment for ischaemia in patients with angina pectoris. We ascertained whether high-dose allopurinol prolongs exercise capability in patients with chronic stable angina.. 65 patients (aged 18-85 years) with angiographically documented coronary artery disease, a positive exercise tolerance test, and stable chronic angina pectoris (for at least 2 months) were recruited into a double-blind, randomised, placebo-controlled, crossover study in a hospital and two infirmaries in the UK. We used computer-generated randomisation to assign patients to allopurinol (600 mg per day) or placebo for 6 weeks before crossover. Our primary endpoint was the time to ST depression, and the secondary endpoints were total exercise time and time to chest pain. We did a completed case analysis. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 82040078.. In the first treatment period, 31 patients were allocated to allopurinol and 28 were analysed, and 34 were allocated to placebo and 32 were analysed. In the second period, all 60 patients were analysed. Allopurinol increased the median time to ST depression to 298 s (IQR 211-408) from a baseline of 232 s (182-380), and placebo increased it to 249 s (200-375; p=0.0002). The point estimate (absolute difference between allopurinol and placebo) was 43 s (95% CI 31-58). Allopurinol increased median total exercise time to 393 s (IQR 280-519) from a baseline of 301 s (251-447), and placebo increased it to 307 s (232-430; p=0.0003); the point estimate was 58 s (95% CI 45-77). Allopurinol increased the time to chest pain from a baseline of 234 s (IQR 189-382) to 304 s (222-421), and placebo increased it to 272 s (200-380; p=0.001); the point estimate was 38 s (95% CI 17-55). No adverse effects of treatment were reported.. Allopurinol seems to be a useful, inexpensive, well tolerated, and safe anti-ischaemic drug for patients with angina.. British Heart Foundation.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Allopurinol; Angina Pectoris; Blood Pressure; C-Reactive Protein; Cardiovascular Agents; Chronic Disease; Cross-Over Studies; Double-Blind Method; Electrocardiography; Enzyme Inhibitors; Exercise Tolerance; Female; Follow-Up Studies; Heart Rate; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Nitroglycerin; Placebos; Time Factors; Vasodilator Agents; Xanthine Oxidase; Young Adult

Assessment of health related quality-of-life (HRQL) has become increasingly important as not only the clinician's view of the technical success, but also the patient's perception is being measured. We evaluated the HRQL following sirolimus-eluting coronary stent (SES) (CYPHER(R); Cordis, Johnson & Johnson, Warren, NJ, USA) implantation in patients with multivessel disease, comparing the outcomes with the historical surgical and bare metal stent (BMS) arms of the ARTS-I study.. The HRQL outcomes were compared to the outcome of the historical cohorts of the randomised ARTS-I trial using the same inclusion and exclusion criteria. HRQL was evaluated at baseline, at one month and at 6, 12 and 36 months after revascularisation using the SF-36 in patients treated with SES (n=585), BMS (n=483) or coronary artery bypass graft (CABG) (n=492). The HRQL compliance rates varied from 100% at baseline to 92% at 36 months. Both stenting and CABG resulted in significant improvement of HRQL and anginal status. There was a trend towards better HRQL after CABG than BMS beyond six months. Already from the first month up to three years, SES patients had, on average, 10% significantly better HRQL than BMS patients on the HRQL subscales physical functioning, role physical functioning, role emotional functioning and mental health (p<0.01) and a trend towards better HRQL in the other subscales. Up to 12 months, the HRQL was better after SES than CABG and was identical thereafter. At all time points, angina was more prevalent in the BMS group than in both the SES and CABG groups, in which the incidence of angina was similar. At three years, 10% of the SES patients suffered from angina, 13% of the CABG patients and 20% of the BMS patients.. Both stenting and CABG resulted in a significant improvement in HRQL and angina. Along with a substantial reduction of restenosis, HRQL after SES was significantly improved as compared with BMS, and was similar to CABG.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chi-Square Distribution; Coronary Artery Bypass; Coronary Artery Disease; Drug-Eluting Stents; Emotions; Female; Humans; Male; Mental Health; Metals; Middle Aged; Prosthesis Design; Quality of Life; Recovery of Function; Registries; Risk Assessment; Risk Factors; Severity of Illness Index; Sirolimus; Stents; Surveys and Questionnaires; Time Factors; Treatment Outcome

Control of heart rate (HR) is an important target during treatment of patients with stable angina. In a number of cases it can be achieved by the use of beta-adrenoblockers. But often a necessity arises to enhance pulse slowing therapy with the use of combinations of drugs exerting negative chronotropic effect. We present here results of the CONTROL study (n=1777), conducted with the aim of studying antianginal efficacy and tolerability of the If-channels blocker ivabradine used in combination with beta-adrenoblockers in patients with stable functional class II-III angina and frequency of attacks > or = 3/week and HR>70 bpm. The use of ivabradine for 12 weeks allowed to achieve greater reduction of frequency of anginal attacks (by 4 per week, 95% confidence interval 3-6) compared with the group of usual care (treatment at physicians discretion). At the end of the study in ivabradine group 43% of patients had no angina at all, HR lowering < or =60 bpm was noted in 46% of patients (in the comparison group14 and 6%, respectively, p < 0.001). Reduction of frequency of attacks of angina correlated with HR lowering, more with pulse rate measured by patients themselves (r = 0.411, p < 0.001), than with values measured at visits to physicians (r = 0.266, p < 0.001). Rate of lethal outcomes as well as rate of nonfatal cardiovascular complications (myocardial infarction, stroke, urgent revascularization) were similar in compared groups. In ivabradine group compared with usual care group there were less hospitalizations (5.0 and 8.6%, respectively, p = 0.021), calls for emergency service (13.3 and 25.4%), and sick leaves (6.6 and 13.1%, p = 0.018). Adverse reactions were noted in 130 patients (8.7%) in ivabradine group and in 29 patients (10.0%) in usual care group p = 0.580).

Topics: Adrenergic beta-Antagonists; Aged; Angina Pectoris; Benzazepines; Cardiovascular Agents; Depression, Chemical; Drug Monitoring; Drug Therapy, Combination; Electrocardiography; Female; Heart Rate; Hospitalization; Humans; Ivabradine; Male; Middle Aged; Prognosis; Severity of Illness Index; Treatment Outcome

To evaluate the anti-anginal and anti-ischaemic efficacy of the selective I(f) current inhibitor ivabradine in patients with chronic stable angina pectoris receiving beta-blocker therapy.. In this double-blinded trial, 889 patients with stable angina receiving atenolol 50 mg/day were randomized to receive ivabradine 5 mg b.i.d. for 2 months, increased to 7.5 mg b.i.d. for a further 2 months, or placebo. Patients underwent treadmill exercise tests at the trough of drug activity using the standard Bruce protocol for randomization and at 2 and 4 months. Total exercise duration at 4 months increased by 24.3 +/- 65.3 s in the ivabradine group, compared with 7.7 +/- 63.8 s with placebo (P < 0.001). Ivabradine was superior to placebo for all exercise test criteria at 4 months (P < 0.001 for all) and 2 months (P-values between <0.001 and 0.018). Ivabradine in combination with atenolol was well tolerated. Only 1.1% of patients withdrew owing to sinus bradycardia in the ivabradine group.. The combination of ivabradine 7.5 mg b.i.d. and atenolol at the commonly used dosage in clinical practice in patients with chronic stable angina pectoris produced additional efficacy with no untoward effect on safety or tolerability.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Angina Pectoris; Atenolol; Benzazepines; Blood Pressure; Cardiovascular Agents; Double-Blind Method; Drug Therapy, Combination; Exercise Test; Exercise Tolerance; Female; Heart Rate; Humans; Ion Channels; Ivabradine; Male; Middle Aged; Sinoatrial Node; Treatment Outcome; Young Adult

This study examined the hypothesis that the improvement in myocardial blood flow (MBF) with ranolazine therapy could be detected by serial automated quantitative myocardial perfusion imaging (MPI) in patients with coronary artery disease (CAD) and myocardial ischemia.. Myocardial ischemia enhances late sodium current, which then causes cellular calcium overload leading to mechanical left ventricular dysfunction and arrhythmias. Ranolazine inhibits late sodium current and improves diastolic tension and MBF in the animal model.. In this open-label, nonrandomized pilot study, we recruited 20 patients with known or a high probability of CAD and who had reversible perfusion defects on exercise treadmill gated single-photon emission computed tomography MPI while receiving conventional antianginal therapy. Ranolazine (up to 1,000 mg twice daily) was added to baseline therapy and a repeat treadmill MPI was obtained after 4 weeks. The extent and severity of total and reversible left ventricular perfusion abnormality (based on polar maps and a 17-segment model) were determined quantitatively using automated methods.. We screened 100 patients for 27 potential candidates; 5 declined and 2 did not complete the follow-up study. The mean age of the remaining 20 patients was 64 +/- 9 years; 30% were women and 50% had diabetes mellitus. The exercise time increased (425 +/- 105 s vs. 393 +/- 116 s, p = 0.017), and angina improved in 15 (75%) patients after ranolazine treatment. In the entire cohort, summed stress scores (10 +/- 7 vs. 13 +/- 8, p = 0.04) and summed difference scores (4.7 +/- 4 vs. 7.4 +/- 5, p = 0.0037) decreased at follow-up. An improvement in perfusion pattern and severity was noted in 14 (70%) patients. In these patients, the polar maps showed a decrease in total abnormality from 26 +/- 17% to 19 +/- 15% and a decrease in the reversible abnormality from 16 +/- 10% to 8 +/- 6% (all p values <0.05).. In this preliminary hypothesis-driven study, short-term ranolazine therapy was shown to improve myocardial perfusion and decrease the ischemic burden in patients with CAD.

Topics: Acetanilides; Aged; Angina Pectoris; Automation, Laboratory; Cardiovascular Agents; Coronary Artery Disease; Coronary Circulation; Exercise Test; Exercise Tolerance; Female; Humans; Male; Middle Aged; Myocardial Ischemia; Myocardial Perfusion Imaging; Pilot Projects; Piperazines; Ranolazine; Severity of Illness Index; Tomography, Emission-Computed, Single-Photon; Treatment Outcome

COURAGE compared outcomes in stable coronary patients randomized to optimal medical therapy plus percutaneous coronary intervention (PCI) versus optimal medical therapy alone.. Angiographic data were analyzed by treatment arm, health care system (Veterans Administration, US non-Veterans Administration, Canada), and gender. Veterans Administration patients had higher prevalence of coronary artery bypass graft surgery and left ventricular ejection fraction < or =50%. Men had worse diameter stenosis of the most severe lesion, higher prevalence of prior coronary artery bypass graft surgery, lower left ventricular ejection fraction, and more 3-vessel disease that included a proximal left anterior descending lesion (P<0.0001 for all comparisons versus women). Failure to cross rate (3%) and visual angiographic success of stent procedures (97%) were similar to contemporary practice in the National Cardiovascular Data Registry. Quantitative angiographic PCI success was 93% (residual lesion <50% in-segment) and 82% (<20% in-stent), with only minor nonsignificant differences among health care systems and genders. Event rates were higher in patients with higher jeopardy scores and more severe vessel disease, but rates were similar irrespective of treatment strategy. Within the PCI plus optimal medical therapy arm, complete revascularization was associated with a trend toward lower rate of death or nonfatal myocardial infarction. Complete revascularization was similar between genders and among health care systems.. PCI success and completeness of revascularization did not differ significantly by health care system or gender and were similar to contemporary practice. Angiographic burden of disease affected overall event rates but not response to an initial strategy of PCI plus optimal medical therapy or optimal medical therapy alone.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Canada; Cardiovascular Agents; Coronary Angiography; Coronary Stenosis; Female; Humans; Male; Morbidity; Myocardial Infarction; Outcome Assessment, Health Care; Prevalence; Severity of Illness Index; Sex Distribution; Stents; United States

This study sought to determine whether initial medical therapy (MT) only or percutaneous coronary intervention plus medical therapy (PCI+MT) is better for patients with low-risk stable coronary artery disease (CAD) indicated for intervention in Japan.. Several multicenter studies have suggested that in the above patients, an initial management strategy of PCI+MT does not reduce the long-term risk of cardiovascular events more effectively than initial MT only.. We conducted a randomized comparative study (JSAP [Japanese Stable Angina Pectoris] study) in the previously mentioned patients.. The patients were randomized to PCI+MT (n = 192) or initial MT only group (n = 192), and the patient characteristics were very similar in the 2 groups. During the 3.3-year follow-up, there was no significant difference in the cumulative death rate between PCI+MT (2.9%) and MT (3.9%). However, the cumulative risk of death plus acute coronary syndrome was significantly smaller in PCI+MT.. In stable low-risk CAD, PCI+MT may improve long-term prognosis more effectively than MT.

Topics: Acute Coronary Syndrome; Adult; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Disease; Female; Humans; Incidence; Japan; Kaplan-Meier Estimate; Male; Middle Aged; Proportional Hazards Models; Risk Assessment; Severity of Illness Index; Time Factors; Treatment Outcome

(1) To evaluate the clinical outcomes of patients with moderate coronary lesions and borderline fractional flow reserve (FFR) measurements (between 0.75 and 0.80), comparing those who underwent coronary revascularization (CR) to those who had medical treatment (MT), and (2) to determine the predictive factors of major adverse cardiac events (MACE) at follow-up.. A total of 107 consecutive patients (mean age 62 +/- 10 years) with at least one moderate coronary lesion (mean percent diameter stenosis 47 +/- 12%) evaluated by coronary pressure wire with FFR measurement between 0.75 and 0.80 (mean 0.77 +/- 0.02) were included in the study. MACE [CR, myocardial infarction (MI), cardiac death) and the presence of angina were evaluated at follow-up.. Sixty-three patients (59%) underwent CR and 44 patients (41%) had MT, with no clinical differences between groups. At a mean follow-up of 13 +/- 7 months, MACE related to the coronary lesion evaluated by FFR were higher in the MT group compared with CR group (23% vs. 5%, P = 0.005). Most MACE consisted of CRs, with no differences between groups in MI and cardiac death rate at follow-up. Both MT and FFR measurements in an artery supplying a territory with previous MI were independent predictive factors of MACE at follow-up, respectively (hazard ratio 5.2, 95% CI 1.4-18.9, P = 0.01; hazard ratio 4.1, 95% CI 1.1-15.3, P = 0.03). The presence of angina at follow-up was more frequent in the MT group compared with the CR group (41% vs. 9%, P = 0.002).. In patients with moderate coronary lesions and borderline FFR measurements deferral of revascularization was associated with a higher rate of MACE (CR) and a higher prevalence of angina at follow-up, especially in those with previous MI in the territory evaluated by FFR. Further prospective randomized studies should confirm whether or not an FFR cut-off point of 0.80 instead of 0.75 would be more appropriate for deferring CR in these cases.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Female; Follow-Up Studies; Fractional Flow Reserve, Myocardial; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Patient Selection; Proportional Hazards Models; Risk Assessment; Risk Factors; Severity of Illness Index; Time Factors; Treatment Outcome

Despite routine use of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), no conclusive evidence exists that either modality is superior to medical therapy (MT) alone for treating multivessel coronary artery disease with stable angina and preserved ventricular function.. The primary end points were total mortality, Q-wave myocardial infarction, or refractory angina requiring revascularization. The study comprised 611 patients randomly assigned to undergo CABG (n=203), PCI (n=205), or MT (n=203). At the 5-year follow-up, the primary end points occurred in 21.2% of patients who underwent CABG compared with 32.7% treated with PCI and 36% receiving MT alone (P=0.0026). No statistical differences were observed in overall mortality among the 3 groups. In addition, 9.4% of MT and 11.2% of PCI patients underwent repeat revascularization procedures compared with 3.9% of CABG patients (P=0.021). Moreover, 15.3%, 11.2%, and 8.3% of patients experienced nonfatal myocardial infarction in the MT, PCI, and CABG groups, respectively (P<0.001). The pairwise treatment comparisons of the primary end points showed no difference between PCI and MT (relative risk, 0.93; 95% confidence interval, 0.67 to 1.30) and a significant protective effect of CABG compared with MT (relative risk, 0.53; 95% confidence interval, 0.36 to 0.77).. All 3 treatment regimens yielded comparable, relatively low rates of death. MT was associated with an incidence of long-term events and rate of additional revascularization similar to those for PCI. CABG was superior to MT in terms of the primary end points, reaching a significant 44% reduction in primary end points at the 5-year follow-up of patients with stable multivessel coronary artery disease.

Topics: Adrenergic beta-Antagonists; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Coronary Restenosis; Diet, Fat-Restricted; Disease-Free Survival; Drug Therapy, Combination; Electrocardiography; Endpoint Determination; Female; Follow-Up Studies; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Nitrates; Prognosis; Reoperation; Stents; Survival Analysis; Treatment Outcome

Ranolazine is a novel antianginal agent that reduces ischemia in patients with chronic angina but has not been studied in patients with acute coronary syndromes (ACS).. To determine the efficacy and safety of ranolazine during long-term treatment of patients with non-ST-elevation ACS.. A randomized, double-blind, placebo-controlled, multinational clinical trial of 6560 patients within 48 hours of ischemic symptoms who were treated with ranolazine (initiated intravenously and followed by oral ranolazine extended-release 1000 mg twice daily, n = 3279) or matching placebo (n = 3281), and followed up for a median of 348 days in the Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndromes (MERLIN)-TIMI 36 trial between October 8, 2004, and February 14, 2007.. The primary efficacy end point was a composite of cardiovascular death, myocardial infarction (MI), or recurrent ischemia through the end of study. The major safety end points were death from any cause and symptomatic documented arrhythmia.. The primary end point occurred in 696 patients (21.8%) in the ranolazine group and 753 patients (23.5%) in the placebo group (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.83-1.02; P = .11). The major secondary end point (cardiovascular death, MI, or severe recurrent ischemia) occurred in 602 patients (18.7%) in the ranolazine group and 625 (19.2%) in the placebo group (HR, 0.96; 95% CI, 0.86-1.08; P = .50). Cardiovascular death or MI occurred in 338 patients (10.4%) allocated to ranolazine and 343 patients (10.5%) allocated to placebo (HR, 0.99; 95% CI, 0.85-1.15; P = .87). Recurrent ischemia was reduced in the ranolazine group (430 [13.9%]) compared with the placebo group (494 [16.1%]; HR, 0.87; 95% CI, 0.76-0.99; P = .03). QTc prolongation requiring a reduction in the dose of intravenous drug occurred in 31 patients (0.9%) receiving ranolazine compared with 10 patients (0.3%) receiving placebo. Symptomatic documented arrhythmias did not differ between the ranolazine (99 [3.0%]) and placebo (102 [3.1%]) groups (P = .84). No difference in total mortality was observed with ranolazine compared with placebo (172 vs 175; HR, 0.99; 95% CI, 0.80-1.22; P = .91).. The addition of ranolazine to standard treatment for ACS was not effective in reducing major cardiovascular events. Ranolazine did not adversely affect the risk of all-cause death or symptomatic documented arrhythmia. Our findings provide support for the safety and efficacy of ranolazine as antianginal therapy.. clinicaltrials.gov Identifier: NCT00099788.

Topics: Acetanilides; Aged; Angina Pectoris; Cardiovascular Agents; Double-Blind Method; Enzyme Inhibitors; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Myocardial Ischemia; Piperazines; Proportional Hazards Models; Ranolazine; Recurrence

A growing population of patients with coronary artery disease experiences angina that is not amenable to revascularization and is refractory to medical therapy. Preclinical studies have indicated that human CD34+ stem cells induce neovascularization in ischemic myocardium, which enhances perfusion and function.. Twenty-four patients (19 men and 5 women aged 48 to 84 years) with Canadian Cardiovascular Society class 3 or 4 angina who were undergoing optimal medical treatment and who were not candidates for mechanical revascularization were enrolled in a double-blind, randomized (3:1), placebo-controlled dose-escalating study. Patients received granulocyte colony-stimulating factor 5 microg x kg(-1) x d(-1) for 5 days with leukapheresis on the fifth day. Selection of CD34+ cells was performed with a Food and Drug Administration-approved device. Electromechanical mapping was performed to identify ischemic but viable regions of myocardium for injection of cells (versus saline). The total dose of cells was distributed in 10 intramyocardial, transendocardial injections. Patients were required to have an implantable cardioverter-defibrillator or to temporarily wear a LifeVest wearable defibrillator. No incidence was observed of myocardial infarction induced by mobilization or intramyocardial injection. The intramyocardial injection of cells or saline did not result in cardiac enzyme elevation, perforation, or pericardial effusion. No incidence of ventricular tachycardia or ventricular fibrillation occurred during the administration of granulocyte colony-stimulating factor or intramyocardial injections. One patient with a history of sudden cardiac death/ventricular tachycardia/ventricular fibrillation had catheter-induced ventricular tachycardia during mapping that required cardioversion. Serious adverse events were evenly distributed. Efficacy parameters including angina frequency, nitroglycerine usage, exercise time, and Canadian Cardiovascular Society class showed trends that favored CD34+ cell-treated patients versus control subjects given placebo.. A randomized trial of intramyocardial injection of autologous CD34+ cells in patients with intractable angina was completed that provides evidence for feasibility, safety, and bioactivity. A larger phase IIb study is currently under way to further evaluate this therapy.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Cell Count; Combined Modality Therapy; Double-Blind Method; Electric Countershock; Electrocardiography, Ambulatory; Exercise Tolerance; Female; Granulocyte Colony-Stimulating Factor; Humans; Injections; Male; Middle Aged; Myocardium; Peripheral Blood Stem Cell Transplantation; Quality of Life; Tomography, Emission-Computed, Single-Photon; Treatment Outcome

To assess the long-term safety and antianginal efficacy of two doses of ivabradine, a novel selective and specific inhibitor of the sinus node I(f) current.. In a randomized double-blind, parallel-group study 386 patients with chronic stable angina were randomized to either ivabradine 5 mg b.i.d. (n = 198, group 1) or ivabradine 7.5 mg b.i.d. (n = 188, group 2) for 12 months. Concomitant medication included antithrombotic agents, lipid-lowering agents, long-acting nitrates and dihydropyridine calcium antagonists. Safety was assessed on the basis of reported adverse events at 1, 3, 6, 9 and 12 months. Antianginal efficacy was based on the reduction in the weekly number of angina attacks and in the consumption of short-acting nitrates from month 0 (baseline) to month 12.. Ivabradine was well tolerated. Phosphene-like mild transient visual symptoms were the most frequently reported adverse events but led to treatment withdrawal in only 4 patients. Resting heart rate was reduced by 9 bpm in group 1 and 12 bpm in group 2. Sinus bradycardia caused treatment withdrawal in only three cases. The QTc (Bazett) interval did not increase. At month 12 relative to month 0 there was a significant reduction in the number of angina attacks per week.. Ivabradine at the recommended doses of 5 and 7.5 mg b.i.d. was well tolerated and demonstrated antianginal efficacy in patients with documented coronary artery disease treated with concomitant antianginal medications.

Topics: Aged; Angina Pectoris; Benzazepines; Cardiovascular Agents; Chronic Disease; Double-Blind Method; Female; Humans; Ivabradine; Male; Middle Aged; Treatment Outcome

Pretreatment is not the most common strategy practiced for clopidogrel administration in elective coronary stenting. Moreover, limited information is available on the antiplatelet pharmacodynamics of a 300-mg versus a 600-mg clopidogrel loading dose, and the comparative effect of eptifibatide with these regimens is unknown.. Patients undergoing elective stenting (n=120) were enrolled in a 2x2 factorial study (300 mg clopidogrel with or without eptifibatide; 600 mg clopidogrel with or without eptifibatide) (Clopidogrel Loading With Eptifibatide to Arrest the Reactivity of Platelets [CLEAR PLATELETS] Study). Clopidogrel was administered immediately after stenting. Aggregometry and flow cytometry were used to assess platelet reactivity. Eptifibatide added a > or =2-fold increase in platelet inhibition to 600 mg clopidogrel alone at 3, 8, and 18 to 24 hours after stenting as measured by 5 micromol/L ADP-induced aggregation (P<0.001). Without eptifibatide, 600 mg clopidogrel produced better inhibition than 300 mg clopidogrel at all time points (P<0.001). Glycoprotein IIb/IIIa (GPIIb/IIIa) blockade was associated with lower cardiac marker release. Active GPIIb/IIIa expression was inhibited most in the groups treated with eptifibatide (P<0.05).. In elective stenting without clopidogrel pretreatment, use of a GPIIb/IIIa inhibitor produces superior platelet inhibition and lower myocardial necrosis compared with high-dose (600 mg) or standard-dose (300 mg) clopidogrel loading alone. In the absence of a GPIIb/IIIa inhibitor, 600 mg clopidogrel provides better platelet inhibition than the standard 300-mg dose. These results require confirmation in a large-scale clinical trial.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clopidogrel; Coronary Stenosis; Coronary Thrombosis; Dose-Response Relationship, Drug; Drug Synergism; Drug Therapy, Combination; Eptifibatide; Female; Humans; Male; Middle Aged; Myocardial Infarction; Myocardium; Necrosis; Peptides; Platelet Aggregation; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Premedication; Risk Factors; Stents; Ticlopidine

The efficacy and safety of a once-daily graded-release diltiazem hydrochloride (GRD) formulation dosed at 10 PM in doses of 180, 360, and 420 mg were compared with placebo and with GRD 360 mg dosed once daily at 8 AM in patients (n = 311) with chronic stable angina pectoris.. This was a 3-week multicenter, randomized, double-blind, double-dummy, parallel-group, placebo-controlled trial. Standard Bruce protocol treadmill stress test was performed at baseline and end point between 6 and 8 PM (trough for evening doses) and between 7 and 11 AM (trough for morning doses).. All GRD evening doses showed a significant (P < or = .0201) increase in total duration of exercise at trough and a greater significant increase (P < or = .0002) at peak, compared with placebo. The GRD 360-mg evening dose showed the greatest increase at trough. In contrast, GRD 360-mg morning dose showed an increase in total duration of exercise at trough that was not significantly different (P = .0555) from placebo AM. GRD 360-mg evening dose showed a 4-fold placebo-adjusted improvement compared with GRD 360-mg morning dose between 7 and 11 AM. Significant increases (P < or = .0240) in time to onset of angina were obtained for all evening doses at trough and peak. All GRD doses were well tolerated, and incidence of adverse events for all GRD groups combined was less than that for placebo.. Bedtime GRD significantly increases exercise tolerance in patients with angina pectoris over the 24-hour dosing interval. A greater 4-fold placebo-adjusted improvement occurred between 7 and 11 AM compared with the same morning dose, coinciding with the period of increased cardiovascular risk. GRD was safe and well tolerated.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Delayed-Action Preparations; Diltiazem; Double-Blind Method; Drug Administration Schedule; Exercise Test; Exercise Tolerance; Female; Humans; Male; Middle Aged; Nitroglycerin

Angiotensin-converting enzyme inhibition is not an effective antianginal therapy. Experimental data suggest that broader vasopeptidase inhibition may decrease the magnitude of demand-induced myocardial ischemia. A randomized, double-blind, placebo controlled parallel study evaluated omapatrilat, an inhibitor of angiotensin-converting enzyme and neutral endopeptidase. The primary objective was to compare maximum duration of exercise at peak plasma concentrations. Exercise treadmill studies were performed in 348 patients who had chronic angina at baseline and after 4 weeks of therapy with 80 mg/day omapatrilat or placebo. Safety data were collected and reported for all patients. Treadmill exercise duration at peak was significantly prolonged in the omapatrilat group compared with the placebo group (76.6 +/- 84.2 vs 28.7 +/- 82.2 seconds difference from baseline, p <0.001). Similar statistically significant increases were seen in time to onset of level III/IV angina and time to onset of >/=0.1-mV ST-segment depression (p <0.001). The significant improvements in exercise duration and measurements of myocardial ischemia were not sustained 20 to 28 hours after dosing. Omapatrilat was generally well tolerated in this predominantly normotensive population. The incidence of serious adverse events was 5.2% in the 2 groups. Thus, omapatrilat, an investigational vasopeptidase inhibitor, is effective in prolonging exercise duration and parameters of demand-induced myocardial ischemia in patients who have chronic angina at peak concentrations. The data confirm the proof of principle that broader vasopeptidase inhibition beyond angiotensin-converting enzyme inhibition is required to alleviate symptoms of chronic angina.

Topics: Angina Pectoris; Angiotensin II; Angiotensin III; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Chronic Disease; Double-Blind Method; Exercise Tolerance; Female; Humans; Male; Middle Aged; Neprilysin; Pyridines; Thiazepines

Little is known about the effect of revascularization in patients > or =75 years of age with symptomatic coronary artery disease (CAD) and diabetes mellitus (DM) for whom periprocedural risk and overall mortality are increased. Therefore, we examined the 301 patients of the Trial of Invasive versus Medical therapy in the Elderly with symptomatic CAD (TIME) with special regard to diabetic status. Patients were randomized to an invasive versus optimized medical strategy. The median follow-up was 4.1 years (range 0.1 to 6.9). Patients with DM (n = 69) had a greater incidence of hypertension (73% vs 58%, p = 0.03), > or =2 risk factors (93% vs 46%, p <0.01), previous heart failure (22% vs 12%, p = 0.04), and previous myocardial infarction (59% vs 43%, p = 0.02), and a lower left ventricular ejection fraction (48% vs 54%, p = 0.02) than did patients without DM. Mortality was greater in patients with DM than in those without DM (41% vs 25%, p = 0.01; adjusted hazard ratio 1.86, p = 0.01). Revascularization improved the overall survival rate from 61% (no revascularization) to 79% (p <0.01; adjusted hazard ratio 1.68, p = 0.03), an effect similarly observed in patients with and without DM. The event-free survival rate was 11% in nonrevascularized patients with DM compared with 40% in nonrevascularized patients without DM and 41% and 53% in revascularized patients with and without DM, respectively (p <0.01). Angina severity and antianginal drug use were similar for patients with and without DM, but those with DM performed worse in daily activities and physical functioning. In conclusion, elderly diabetic patients with chronic angina have a worse outcome than those with DM but benefit similarly from revascularization regarding symptom relief and long-term outcome. However, physical functioning related to daily activities is reduced in those with DM and may need special attention.

Topics: Age Factors; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Diabetes Mellitus; Female; Humans; Male; Myocardial Revascularization; Probability; Prognosis; Proportional Hazards Models; Quality of Life; Reference Values; Risk Assessment; Severity of Illness Index; Statistics, Nonparametric; Survival Analysis; Time Factors

Plaque stabilization by statins is important for reduction of cardiovascular events but has not been demonstrated enough in vivo. We examined whether statins clinically alter the structure of coronary atherosclerotic plaques using intravascular ultrasound (IVUS) radio-frequency (RF) signal analysis.. Fifty consecutive patients undergoing percutaneous coronary intervention were enrolled. Intravascular ultrasound radio-frequency signals were acquired from non-percutaneous coronary intervention-targeted echolucent plaques. The patients were randomly assigned into 2 groups: group S (n = 25) taking atorvastatin 10 mg/d and group C (n = 25) as control. After 6-month follow-up, IVUS-RF signals were sampled at the same plaque sites. Several regions of interest were placed on each plaque. Intravascular ultrasound radio-frequency parameters were blindly calculated in all regions of interests (group S, n = 148; group C, n = 191). Targeted plaque volumes were also measured. Those data were compared between baseline and follow-up.. In group S after 6 months, plasma low-density lipoprotein level was significantly decreased (133 +/- 13 to 87 +/- 29 mg/dL, P < .0001), integrated backscatter of IVUS-RF signals was substantially increased (-53.8 +/- 4.5 to -51.2 +/- 4.9 dB, P < .0001), and plaque volume was significantly reduced, whereas no change was demonstrated in group C.. These results suggest that statins alter properties as well as volumes of coronary plaques within 6 months, which may be related to plasma low-density lipoprotein reduction. Intravascular ultrasound radio-frequency signal analysis may be useful to evaluate the effects of drugs on stabilization of coronary atherosclerotic plaques.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Atorvastatin; Cardiovascular Agents; Cholesterol, LDL; Comorbidity; Coronary Artery Disease; Female; Follow-Up Studies; Heptanoic Acids; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypercholesterolemia; Male; Middle Aged; Prospective Studies; Pyrroles; Radio Waves; Single-Blind Method; Treatment Outcome; Ultrasonography, Interventional

To assess the efficacy of the Coronary Heart Disease (CHD) Capsules worked out by Prof. Deng --in improving quality of life of CHD patients of qi deficiency with phlegm and blood stasis syndrome.. According to the WHO's diagnosis criteria of CHD, a total of 93 stable angina patients were divided into 3 groups using the single blinded method. The groups were evenly distributed into CHD Capsule treated group (CHDC), isosorbide dinitrate control group (ID), and Compound Prescription Danshen Droplet Pills control group (CPDDP). Two courses of treatment lasting for 6 months were given. During the courses of treatment, the following parameters were observed: clinical symptoms of angina pectoris, ECG change, treadmill exercise test, 36 items in short form of health survey (SF-36) and Seattle Angina Questionnaire (SAQ) scale.. After 6 months of treatment, all the three groups showed good curative effect in angina pectoris, ECG and treadmill exercise test, differences between them had no statistical significance. The CHDC group showed a better result in nitro-glycerine stopping or alleviation rate and in improving symptoms than the other groups (P < 0.05). The general health, vitality, role-emotional, mental health and reported health transition in the CHDC group were significantly better than those in the control groups (P < 0.05). The scores in physiological functioning role, physiological function and pain alleviation were not different among the three groups.. Prof. DENG Tie-tao's CHDC is effective in treating CHD with qi deficiency, phlegm and blood stasis and also in improving the quality of life. CHDC is more suitable to be used in long-term treatment than isosorbide dinitrate. The SF-36 and SAQ can be used to appraise the curative effect of traditional Chinese medicine agents for CHD angina pectoris.

Topics: Aged; Angina Pectoris; Capsules; Cardiovascular Agents; Coronary Disease; Drugs, Chinese Herbal; Female; Humans; Isosorbide Dinitrate; Male; Medicine, Chinese Traditional; Middle Aged; Phytotherapy; Plant Preparations; Quality of Life; Salvia miltiorrhiza; Single-Blind Method; Treatment Outcome

To evaluate the clinical effect and safety of Safflower Yellow injection (SYI) in treating coronary heart disease angina pectoris (CHD-AP) with Xin-blood stagnation syndrome (XBSS).. Adopted was the multi-centered, randomized, positive parallel controlled method, 448 patients with CHD-AP-XBSS were enrolled and divided into two groups, 336 in the tested group treated with SYI and 112 in the control group treated with Salvia injection by intravenous dripping once a day for 14 days, so as to observe the conditions of angina, electrocardiogram, and therapeutic effect on traditional Chinese medicine (TCM) symptoms as well as the safety of the treatment.. The significantly effective rate and total effective rate in the tested group were 60.06% (194/323) and 91.02% (294/323) respectively; Those in improvement of TCM symptoms were 40.18% (129/321) and 75.23% (243/323) respectively, which were better than those in the control group (P < 0.01).. SYI Injection is effective and safe in treating CHD-AP-XBSS.

Topics: Adolescent; Adult; Aged; Angina Pectoris; Cardiovascular Agents; Chalcone; Female; Humans; Infusions, Intravenous; Male; Medicine, Chinese Traditional; Middle Aged; Phytotherapy; Plant Preparations; Salvia; Treatment Outcome

Ivabradine, a new I(f) inhibitor which acts specifically on the pacemaker activity of the sinoatrial node, is a pure heart rate lowering agent. Ivabradine has shown anti-ischaemic and anti-anginal activity in a placebo-controlled trial. The objective of this study was to compare the anti-anginal and anti-ischaemic effects of ivabradine and the beta-blocker atenolol.. In a double-blinded trial, 939 patients with stable angina were randomized to receive ivabradine 5 mg bid for 4 weeks and then either 7.5 or 10 mg bid for 12 weeks or atenolol 50 mg od for 4 weeks and then 100 mg od for 12 weeks. Patients underwent treadmill exercise tests at randomization (M(0)) and after 4 (M(1)) and 16 (M(4)) weeks of therapy. Increases in total exercise duration (TED) at trough at M(4) were 86.8+/-129.0 and 91.7+/-118.8 s with ivabradine 7.5 and 10 mg, respectively and 78.8+/-133.4 s with atenolol 100 mg. Mean differences (SE) when compared with atenolol 100 mg were 10.3 (9.4) and 15.7 (9.5) s in favour of ivabradine 7.5 and 10 mg (P<0.001 for non-inferiority). TED at M(1) improved by 64.2+/-104.0 s with ivabradine 5 mg and by 60.0+/-114.4 s with atenolol 50 mg (P<0.001 for non-inferiority). Non-inferiority of ivabradine was shown at all doses and for all criteria. The number of angina attacks was decreased by two-thirds with both ivabradine and atenolol.. Ivabradine is as effective as atenolol in patients with stable angina.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Atenolol; Benzazepines; Cardiovascular Agents; Chronic Disease; Double-Blind Method; Exercise Tolerance; Female; Heart Conduction System; Humans; Ion Channels; Ivabradine; Male; Middle Aged

Many patients with chronic angina experience anginal episodes despite revascularization and antianginal medications. In a previous trial, antianginal monotherapy with ranolazine, a drug believed to partially inhibit fatty acid oxidation, increased treadmill exercise performance; however, its long-term efficacy and safety have not been studied in combination with beta-blockers or calcium antagonists in a large patient population with severe chronic angina.. To determine whether, at trough levels, ranolazine improves the total exercise time of patients who have symptoms of chronic angina and who experience angina and ischemia at low workloads despite taking standard doses of atenolol, amlodipine, or diltiazem and to determine times to angina onset and to electrocardiographic evidence of myocardial ischemia, effect on angina attacks and nitroglycerin use, and effect on long-term survival in an open-label observational study extension.. A randomized, 3-group parallel, double-blind, placebo-controlled trial of 823 eligible adults with symptomatic chronic angina who were randomly assigned to receive placebo or 1 of 2 doses of ranolazine. Patients treated at the 118 participating ambulatory outpatient settings in several countries were enrolled in the Combination Assessment of Ranolazine In Stable Angina (CARISA) trial from July 1999 to August 2001 and followed up through October 31, 2002.. Patients received twice-daily placebo or 750 mg or 1000 mg of ranolazine. Treadmill exercise 12 hours (trough) and 4 hours (peak) after dosing was assessed after 2, 6 (trough only), and 12 weeks of treatment.. Change in exercise duration, time to onset of angina, time to onset of ischemia, nitroglycerin use, and number of angina attacks.. Trough exercise duration increased by 115.6 seconds from baseline in both ranolazine groups (pooled) vs 91.7 seconds in the placebo group (P =.01). The times to angina and to electrocardiographic ischemia also increased in the ranolazine groups, at peak more than at trough. The increases did not depend on changes in blood pressure, heart rate, or background antianginal therapy and persisted throughout 12 weeks. Ranolazine reduced angina attacks and nitroglycerin use by about 1 per week vs placebo (P<.02). Survival of 750 patients taking ranolazine during the CARISA trial or its associated long-term open-label study was 98.4% in the first year and 95.9% in the second year.. Twice-daily doses of ranolazine increased exercise capacity and provided additional antianginal relief to symptomatic patients with severe chronic angina taking standard doses of atenolol, amlodipine, or diltiazem, without evident adverse, long-term survival consequences over 1 to 2 years of therapy.

Topics: Acetanilides; Adrenergic beta-Antagonists; Aged; Amlodipine; Angina Pectoris; Atenolol; Calcium Channel Blockers; Cardiovascular Agents; Chronic Disease; Diltiazem; Double-Blind Method; Drug Therapy, Combination; Electrocardiography; Exercise Test; Female; Hemodynamics; Humans; Male; Middle Aged; Myocardial Ischemia; Nitroglycerin; Physical Exertion; Piperazines; Ranolazine; Survival Analysis

Perhexiline is an antianginal agent that displays both saturable and polymorphic metabolism via CYP2D6. The aim of this study was to determine whether perhexiline produces clinically significant inhibition of CYP2D6-catalysed metabolism in angina patients.. The effects of perhexiline on CYP2D6-catalysed metabolism were investigated by comparing urinary total dextrorphan/dextromethorphan metabolic ratios following a single dose of dextromethorphan (16.4 mg) in eight matched control patients not taking perhexiline and 24 patients taking perhexiline. All of the patients taking perhexiline had blood drawn for CYP2D6 genotyping as well as to measure plasma perhexiline and cis-OH-perhexiline concentrations.. Median (range) dextrorphan/dextromethorphan metabolic ratios were significantly higher (P < 0.0001) in control patients, 271.1 (40.3-686.1), compared with perhexiline-treated patients, 5.0 (0.3-107.9). In the perhexiline-treated group 10/24 patients had metabolic ratios consistent with poor metabolizer phenotypes; however, none was a genotypic poor metabolizer. Interestingly, 89% of patients who had phenocopied to poor metabolizers had only one functional CYP2D6 gene. There was a significant negative linear correlation between the log of the dextrorphan/dextromethorphan metabolic ratio and plasma perhexiline concentrations (r(2) = 0.69, P < 0.0001). Compared with patients with at least two functional CYP2D6 genes, those with one functional gene were on similar perhexiline dosage regimens but had significantly higher plasma perhexiline concentrations, 0.73 (0.21-1.00) vs. 0.36 (0.04-0.69) mg l(-1) (P = 0.04), lower cis-OH-perhexiline/perhexiline ratios, 2.85 (0.35-6.10) vs. 6.51 (1.84-11.67) (P = 0.03), and lower dextrorphan/dextromethorphan metabolic ratios, 2.51 (0.33-39.56) vs. 11.80 (2.90-36.93) (P = 0.005).. Perhexiline significantly inhibits CYP2D6-catalysed metabolism in angina patients. The plasma cis-OH-perhexiline/perhexiline ratio may help to both phenotype patients and predict those in whom perhexiline may be most likely to cause clinically significant metabolic inhibition.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Cytochrome P-450 CYP2D6 Inhibitors; Dextromethorphan; Dextrorphan; Female; Humans; Male; Perhexiline

We sought to evaluate the relative efficacies of three possible therapeutic strategies for patients with multivessel coronary artery disease (CAD), stable angina, and preserved ventricular function.. Despite routine use of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI), there is no conclusive evidence that either one is superior to medical therapy (MT) alone for the treatment of multivessel CAD.. The primary end point was defined as cardiac mortality, Q-wave myocardial infarction (MI), or refractory angina requiring revascularization. All data were analyzed according to the intention-to-treat principle.. A total of 611 patients were randomly assigned to either a CABG (n = 203), PCI (n = 205), or MT (n = 203) group. The one-year survival rates were 96.0% for CABG, 95.6% for PCI, and 98.5% for MT. The rates for one-year survival free of Q-wave MI were 98% for CABG, 92% for PCI, and 97% for MT. After one-year follow-up, 8.3% of MT patients and 13.3% of PCI patients underwent to additional interventions, compared with only 0.5% of CABG patients. At one-year follow-up, 88% of the patients in the CABG group, 79% in the PCI group, and 46% in the MT group were free of angina (p < 0.0001).. Medical therapy for multivessel CAD was associated with a lower incidence of short-term events and a reduced need for additional revascularization, compared with PCI. In addition, CABG was superior to MT for eliminating anginal symptoms. All three therapeutic regimens yielded relatively low rates of cardiac-related deaths.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Humans; Survival Analysis; Treatment Outcome; Ventricular Function

Stent implantation for isolated stenosis of the proximal left anterior descending coronary artery (LAD) with preserved left ventricular function has been found to have a better clinical and angiographic outcome at one year than balloon angioplasty (PTCA).. To establish whether those results are maintained at five year follow up.. Patients were followed at least every six months. For those who died during follow up, data were obtained from medical records.. Freedom from death, non-fatal myocardial infarction, cerebrovascular accident, and repeated target lesion revascularisation. Secondary end points were revascularisation in a remote region and freedom from angina.. Follow up was complete in all patients. At five years, the primary end point was reached more often by patients randomised to stent implantation than to PTCA (80% v 53%; odds ratio (OR) 0.29 (95% confidence interval (CI) 0.13 to 0.69); p = 0.0034). In the PTCA group, 35% of patients underwent target lesion revascularisation v 15% in the stent group (OR 0.33, 95% CI 0.13 to 0.80; p = 0.014). There was a trend towards increased mortality in the PTCA group than in the stent group (17% v 7%; OR 0.36, 95% CI 0.10 to 1.21; p = 0.098). No significant differences were found between PTCA and stent groups for non-fatal myocardial infarction (8% v 5%; OR 0.58, 95% CI 0.13 to 2.54; p = 0.46) or cerebrovascular accident (2% v 0%).. In patients with isolated stenosis of the proximal LAD, a five year clinical follow up confirmed a better outcome in those treated with stenting than with PTCA.

Topics: Acute Disease; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Stenosis; Follow-Up Studies; Humans; Myocardial Infarction; Myocardial Ischemia; Myocardial Revascularization; Stents; Treatment Outcome

To assess treatment effects of optimised medical therapy and PCI or CABG surgery on one-year outcome in patients 75 years old with chronic angina.. On-treatment analysis of the TIME data: all re-vascularised patients (REVASC n=174: 112 randomised to revascularisation and 62 to drugs with late revascularisation) were compared to all patients on continued drug therapy (MED n=127: 86 randomised to drugs and 41 to revascularisation only). Baseline characteristics of both groups were similar (age 80 +/- 4 years). Risk of death at one year (adjusted hazard ratio (HR)=1.31; 95%-CI: 0.58-2.99; P=0.52) and of death/infarction (adjusted hazard RATIO=1.77; 95%-CI 0.91-3.41; P=0.09) were comparable between REVASC and MED patients. Furthermore, the risk of death within 30 days was even slightly lower among REVASC patients (unadjusted hazard RATIO=0.73; 95%-CI: 0.21-2.53; P=0.98). Overall, REVASC patients had greater improvements in symptoms and well-being than MED patients (P<0.01). Surgical patients had similar mortality rates as angioplasty patients, but they also had greater symptomatic improvements (P<0.01).. Treated medically, elderly patients with chronic angina have a similarly high 30-day and one-year mortality as patients of the same age being re-vascularised; however, they can expect lower improvements in symptoms and well being.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Angioplasty, Balloon; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Female; Humans; Male; Myocardial Revascularization; Proportional Hazards Models; Prospective Studies; Quality of Life; Risk Factors; Survival Analysis; Treatment Outcome

Transmyocardial laser revascularization (TMR) is an effective treatment for relief of refractory angina. This benefit may be mediated by increase in myocardial perfusion or by cardiac denervation. We investigate the efficacy of TMR and thoracic sympathectomy (TS) for relief of angina and whether any clinical benefit is associated with enhanced myocardial perfusion.. Twenty consecutive patients with nonrevascularizable coronary arteries and intractable angina were prospectively randomized to have TMR by holmium: yttrium aluminum garnet laser or TS. Subjects were clinically evaluated before, and for 42 months after, surgery. They underwent exercise tolerance testing and rest and stress quantitative perfusion magnetic resonance imaging (MRI) before, and 6 months after surgery.. The demographics of the two groups were similar. There was no perioperative mortality; however, two patients died in the TS group during follow-up. The Canadian Cardiovascular Society angina score improved from 3.4 +/- 0.5 to 2.6 +/- 1.1 (p = 0.06) in the TS group at 6 months but returned to 3.2 +/- 0.7 at 42 months, while in the TMR group it improved from 3.6 +/- 0.5 to 1.9 +/- 0.7 (p = 0.008) at 6 months and deteriorated to 2.5 +/- 0.9 (p = 0.01) after 42 months of surgery. The TMR-treated patients showed significant improvements in the SF-36 scores and Seattle Angina Questionnaire only at 6 months, whereas TS-treated patients did not show amelioration at any time during follow-up. The MRI protocol was completed in 15 of 20 (TMR = 8; TS = 7) patients and no significant differences in qualitative or quantitative perfusion variables were demonstrated in either group.. A greater clinical benefit was obtained with TMR than with TS early after surgery but this clinical effect did not seem to be associated with improvement in myocardial perfusion as assessed by MRI and part of the beneficial effect was lost by 42 months after surgery.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Coronary Circulation; Exercise Test; Exercise Tolerance; Female; Heart; Humans; Laser Therapy; Magnetic Resonance Imaging; Male; Middle Aged; Myocardial Revascularization; Myocardium; Neovascularization, Physiologic; Prospective Studies; Quality of Life; Surveys and Questionnaires; Sympathectomy; Thoracotomy; Treatment Outcome

Endothelial dysfunction is associated with inflammation and postprandial hypertriglyceridemia. Xuezhikang, an extract of Cholestin, a dietary supplement, has lipid-modulating and antiinflammatory effects. We explored the effects of xuezhikang on endothelial function and high-sensitivity C-reactive protein (hs-CRP) in patients with coronary heart disease (CHD).. We prospectively randomized 50 CHD patients to xuezhikang 1200 mg/d or placebo for 6 weeks. Fasting hs-CRP concentrations, flow-mediated vasodilation (FMD) at 0 and 4 hours, and lipid parameters at 0, 2, 4, and 6 hours were monitored after a high-fat meal (800 calories; 50 g fat) in all patients. All patients underwent a high-fat meal test at the beginning of the study and after 6 weeks of treatment. Postprandial FMD was significantly worse at 4 hours after a high-fat meal (P<0.05), and this was associated with the area under the triglyceride curve (TG-AUC) (r=0.345, P<0.01). After 6 weeks of xuezhikang, fasting hs-CRP levels and TG-AUC (P<0.001 for each) decreased. Furthermore, preprandial and postprandial FMD significantly improved (P<0.001). There were no significant changes in serum lipids and FMD in the placebo arm. In multivariable regression analysis, changes in TG-AUC and fasting hs-CRP levels were predictive of improvement in preprandial FMD (P<0.05).. Xuezhikang effectively improved preprandial and postprandial endothelial function through its potent antiinflammatory and lipid-lowering effects.

Topics: Angina Pectoris; Anti-Inflammatory Agents, Non-Steroidal; Biological Products; Biomarkers; Brachial Artery; C-Reactive Protein; Cardiovascular Agents; Dietary Fats; Drugs, Chinese Herbal; Endothelium, Vascular; Fasting; Female; Humans; Hypertriglyceridemia; Hypolipidemic Agents; Male; Middle Aged; Postprandial Period; Prospective Studies; Treatment Outcome; Triglycerides; Vasodilation

There are no prospective trial data on long-term outcomes in 80-year-old patients with chronic angina with regard to antiischemic therapy.. To assess long-term survival and quality of life (QoL) in patients from the Trial of Invasive versus Medical Therapy in the Elderly (TIME), all 276 1-year survivors (of a total 301 patients) were contacted after a median of 3.1 years (range, 1.1 to 5.9 years). At baseline, patients were 80+/-4 years old, 42% were women, and they were designated as being in angina class 3.2+/-0.7, despite their taking 2.5+/-0.7 antiischemic drugs. Patients were randomized to an invasive (n=153) or an optimized medical (n=148) strategy. Survival of invasive-strategy versus medical-strategy patients was 91.5% versus 95.9% after 6 months, 89.5% versus 93.9% after 1 year, and 70.6% versus 73.0% after 4.1 years (P=NS). Mortality was independently increased in patients >or=80 years of age, with prior heart failure, ejection fraction or=2 comorbidities, and without revascularization within the first year. Revascularization within the first year improved survival in invasive-strategy (P=0.07) and medical-strategy (P<0.001) patients. The early benefit of both treatments in angina relief and QoL was maintained long term, but freedom from major events remained higher in invasive-strategy versus medical-strategy patients (39% versus 20%, P<0.0001).. Long-term survival was similar for patients assigned to invasive and medical treatment. The benefits of both treatments in angina relief and improvement in QoL were maintained, but nonfatal events occurred more frequently in patients assigned to medical treatment. Irrespective of whether patients were catheterized initially or only after drug therapy failure, their survival rates were better if they were revascularized within the first year.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Diabetes Mellitus, Type 2; Female; Follow-Up Studies; Hospitalization; Humans; Life Tables; Male; Myocardial Revascularization; Prognosis; Proportional Hazards Models; Prospective Studies; Quality of Life; Recurrence; Survival Analysis; Switzerland; Time Factors; Treatment Outcome

The risk-benefit ratio of invasive vs medical management of elderly patients with symptomatic chronic coronary artery disease (CAD) is unclear. The Trial of Invasive versus Medical therapy in Elderly patients (TIME) recently showed early benefits in quality of life from invasive therapy in patients aged 75 years or older, although with a certain excess in mortality.. To assess the long-term value of invasive vs medical management of chronic CAD in elderly adults in terms of quality of life and prevention of major adverse cardiac events.. One-year follow-up analysis of TIME, a prospective randomized trial with enrollment between February 1996 and November 2000.. A total of 282 patients with Canadian Cardiac Society class 2 or higher angina despite treatment with 2 or more anti-anginal drugs who survived for the first 6 months after enrollment in TIME (mean age, 80 years [range, 75-91 years]; 42% women), enrolled at 14 centers in Switzerland.. Participants were randomly assigned to undergo coronary angiography followed by revascularization (if feasible) (n = 140 surviving 6 months) or to receive optimized medical therapy (n = 142 surviving 6 months).. Quality of life, assessed by standardized questionnaire; major adverse cardiac events (death, nonfatal myocardial infarction, or hospitalization for acute coronary syndrome) after 1 year.. After 1 year, improvements in angina and quality of life persisted for both therapies compared with baseline, but the early difference favoring invasive therapy disappeared. Among invasive therapy patients, later hospitalization with revascularization was much less likely (10% vs 46%; hazard ratio [HR], 0.19; 95% confidence interval [CI], 0.11-0.32; P<.001). However, 1-year mortality (11.1% for invasive; 8.1% for medical; HR, 1.51; 95% CI, 0.72-3.16; P =.28) and death or nonfatal myocardial infarction rates (17.0% for invasive; 19.6% for medical; HR, 0.90; 95% CI, 0.53-1.53; P =.71) were not significantly different. Overall major adverse cardiac event rates were higher for medical patients after 6 months (49.3% vs 19.0% for invasive; P<.001), a difference which increased to 64.2% vs 25.5% after 12 months (P<.001).. In contrast with differences in early results, 1-year outcomes in elderly patients with chronic angina are similar with regard to symptoms, quality of life, and death or nonfatal infarction with invasive vs optimized medical strategies based on this intention-to-treat analysis. The invasive approach carries an early intervention risk, while medical management poses an almost 50% chance of later hospitalization and revascularization.

Topics: Aged; Angina Pectoris; Cardiac Catheterization; Cardiovascular Agents; Chronic Disease; Coronary Angiography; Coronary Artery Disease; Female; Follow-Up Studies; Humans; Male; Myocardial Revascularization; Quality of Life; Risk Assessment; Survival Analysis; Treatment Outcome

This study was designed to compare the long-term consequences of percutaneous transluminal coronary angioplasty (PTCA) and continued medical treatment.. The long-term effects of percutaneous coronary intervention need evaluating, especially in comparison with an alternative policy of continued medical treatment.. The Second Randomized Intervention Treatment of Angina (RITA-2) is a randomized trial of PTCA versus conservative (medical) care in 1,018 patients considered suitable for either treatment option. Information on clinical events, interventions, and symptoms is available for a median seven years follow-up.. Death or myocardial infarction (MI) occurred in 73 (14.5%) PTCA patients and 63 (12.3%) medical patients (difference +2.2%, 95% confidence interval -2.0% to +6.4%, p = 0.21). There were 43 deaths in both groups, of which 41% were cardiac-related. Among patients assigned PTCA 12.7% subsequently had coronary artery bypass grafts, and 14.5% required additional non-randomized PTCA. Most of these re-interventions occurred within a year of randomization, and after two years the re-intervention rate was 2.3% per annum. In the medical group, 35.4% required myocardial revascularization: 15.0% in the first year and an annual rate of 3.6% after two years. An initial policy of PTCA was associated with improved anginal symptoms and exercise times. These treatment differences narrowed over time, mainly because of coronary interventions in medical patients with severe symptoms.. In RITA-2 an initial strategy of PTCA did not influence the risk of death or MI, but it improved angina and exercise tolerance. Patients considered suitable for PTCA or medical therapy can be safely managed with continued medical therapy, but percutaneous intervention is appropriate if symptoms are not controlled.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Exercise Test; Female; Humans; Longitudinal Studies; Male; Middle Aged; Myocardial Infarction; Severity of Illness Index; Treatment Outcome; United Kingdom

The second Randomized Intervention Treatment of Angina (RITA-2) trial compares an initial strategy of PTCA with continued medical management in patients with arteriographically proven coronary artery disease. This paper employs resource use data collected in the trial to compare the health service costs of the two strategies over 3 years follow-up.. 1018 patients were randomized, 504 to PTCA and 514 to continued medical management. Health service resource use data were collected prospectively on all patients. Hospital unit costs were estimated in collaboration with five U.K. centres. PTCA patients underwent more subsequent coronary arteriograms, but subsequent (non-randomized) PTCAs were more common in patients randomized to medical management (118 procedures in 102 patients) compared to those randomized to PTCA (73 procedures in 62 patients). The likelihood of undergoing CABG was similar in the two groups. The use of antianginal medications was higher in patients randomized to an initial strategy of medical management. There was an overall mean additional cost per patient over 3 years in patients randomized to PTCA of pound 2685 (95% CI pound 2074- pound 3322).. In RITA-2, the cost of an initial strategy of PTCA exceeded the cost of an initial strategy of medical management by 74% over 3 years.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Follow-Up Studies; Health Care Costs; Health Resources; Health Services Research; Hospital Costs; Hospitalization; Humans; Ireland; Prospective Studies; United Kingdom

To examine whether the prophylactic antianginal agent perhexiline potentiates platelet responsiveness to nitric oxide (NO) in patients with stable angina pectoris (SAP) and acute coronary syndromes (ACS: unstable angina pectoris or non-Q-wave myocardial infarction).. Blood samples were obtained from patients before and after initiation of treatment with perhexiline. ADP-induced platelet aggregation and its inhibition by the NO donor sodium nitroprusside (SNP) were determined via impedance aggregometry in whole blood (WB) and platelet-rich plasma (PRP). Intraplatelet cGMP content was assayed by RIA, and superoxide (O(2)(-)) level by lucigenin-derived chemiluminescence. In patients with ACS not receiving perhexiline (n=12), platelet responsiveness to SNP did not vary significantly over the first 3 days post admission to hospital. Therapy with perhexiline for 3 days was associated with increases in SNP-induced inhibition of aggregation from 29+/-2% to 43+/-4% (n=50,P <0.001) in WB and from 20+/-5% to 42+/-7% (n=12, P<0.01) in PRP. Resolution of symptomatic ischaemia (n=39) was associated with significantly greater (P<0.01) increases than non-resolution (n=11). Similar increases in SNP responsiveness (P<0.001) occurred following institution of perhexiline therapy in patients with SAP (n=30), associated with a 85% decrease in anginal frequency. Treatment with perhexiline potentiated the cGMP-elevating effects of SNP in platelets (n=9,P =0.03). Although perhexiline did not alter whole blood O(2)(-) concentration ex vivo, it inhibited (P<0.01) O(2)(-) release from neutrophils in vitro.. Perhexiline potentiates platelet responsiveness to NO both in SAP and ACS patients; in the latter group this improvement was predictive of resolution of ischaemic symptoms. The predominant mechanism of perhexiline effect is an increase in platelet cGMP responsiveness. Perhexiline also may reduce the potential for NO clearance by neutrophil-derived O(2)(-).

Topics: Aged; Angina Pectoris; Blood Platelets; Cardiovascular Agents; Coronary Disease; Cyclic GMP; Female; Humans; Male; Neutrophils; Nitric Oxide; Nitric Oxide Donors; Nitroprusside; Perhexiline; Platelet Aggregation; Superoxides

A randomized, double-blind, parallel-group study comparing the efficacy and tolerability of once-daily diltiazem capsules with amlodipine tablets in patients with stable angina. After a run-in period of 1 to 3 weeks, 34 patients received once-daily diltiazem and 33 patients received amlodipine. Patients received either diltiazem, 240 mg/day, or amlodipine, 5 mg/day, for 2 weeks followed by diltiazem, 360 mg/day, or amlodipine, 10 mg/day, for 2 weeks. Standard treadmill exercise testing was the primary efficacy assessment. Patients also recorded incidence of angina attacks and use of glyceryl trinitrate spray. Both treatments gave significant improvement in time to onset of angina and time to maximal exercise. With the exception of amlodipine, 5 mg/day, both treatments gave significant increases in time to 1-mm ST segment depression. Diltiazem, 360 mg/day, gave a significant decrease in rate pressure product. There were no significant treatment differences in any of the exercise test parameters. Both treatments reduced incidence of angina attacks and use of glyceryl trinitrate spray. The incidence of edema was significantly less in patients receiving diltiazem. In conclusion, both treatments were effective in controlling patients' angina, but diltiazem was better tolerated, with a lower incidence of edema.

Topics: Adult; Aged; Amlodipine; Angina Pectoris; Blood Pressure; Calcium Channel Blockers; Cardiovascular Agents; Diltiazem; Double-Blind Method; Drug Administration Schedule; Exercise Tolerance; Female; Heart Rate; Humans; Male; Middle Aged; Nitroglycerin; Time Factors; Treatment Outcome; Vasodilator Agents

In patients with stable angina pectoris or silent myocardial ischemia, who had signs of ischemia in ECG during exercise, the Asymptomatic Cardiac Ischemia Pilot (ACIP) study compared 2 types of medication strategies (ischemia-guided and angina-guided) and a strategy of primary revascularization by PTCA or CABG. ACIP substantiated, after 2 years of observation, a clear advantage of the revascularization strategy compared to both drug strategies in terms of clinical effectiveness. This advantage is even more distinct in patients with very severe angiographic results.. This is a retrospective, incremental cost-effectiveness analysis from the perspective of the German third party payer (statutory sick funds) on the basis of the ACIP study.. The direct costs of the revascularization strategy after 2 years are about 2 to 3 times higher than those of the drug therapies. The incremental cost-effectiveness of the ischemia-guided strategy versus an angina-guided strategy is DM 2,600 per life-year saved. Furthermore, the cost-effectiveness of a revascularization strategy versus an angina guided therapy is DM 15,100 per life-year saved.. A primary revascularization strategy is cost-effective in patients with stable coronary artery disease with proven myocardial ischemia and positive angiographic signs.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Cost-Benefit Analysis; Disease Management; Female; Germany; Humans; Male; Middle Aged; Myocardial Ischemia; Myocardial Revascularization; Pilot Projects; Randomized Controlled Trials as Topic; Retrospective Studies; Single-Blind Method; Survival Analysis

Correction of the metabolic link of the natural course of ischemic heart disease (IHD) was found out to be a real reserve of enhancement of therapy efficiency in treating this condition. A total of 137 IHD patients were examined, presenting with functional class II-III exertional angina, their age ranging between 67 to 86 years. Kinds of metabolic complexes to be used in IHD treatment included amino acids, antioxidants, cofactors, energy-providing compounds that enhance efficiency of basic methods of IHD therapy. A positive therapeutic effect of metabolic correction treatments was evidenced by earlier dispelling of electrocardiographic signs of myocardial ischemia, higher tolerance to physical load, improvement in parameters characterizing cardio-hemodynamics.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Drug Therapy, Combination; Energy Metabolism; Heart; Hemodynamics; Humans; Myocardial Ischemia; Myocardium

Percutaneous transmyocardial laser revascularisation (PTMR) is a proposed catheter-based therapy for refractory angina pectoris when bypass surgery or angioplasty is not possible. We undertook a randomised trial to assess the safety and efficacy of this technique.. 221 patients with reversible ischaemia of Canadian Cardiovascular Society angina class III (61%) or IV (39%) and incomplete response to other therapies were recruited from 13 centres. Patients were randomly assigned PTMR with a holmium:YAG laser plus continued medical treatment (n=110) or continued medical treatment only (n=111). The primary endpoint was the exercise tolerance at 12 months. Analyses were by intention to treat.. 11 patients died and 19 withdrew; 92 PTMR-group and 99 medical-treatment-group patients completed the study. Exercise tolerance at 12 months had increased by a median of 89.0 s (IQR -15 to 183) with PTMR compared with 12.5 s (-67 to 125) with medical treatment only (p=0.008). On masked assessment, angina class was II or lower in 34.1% of PTMR patients compared with 13.0% of those medically treated. All indices of the Seattle angina questionnaire improved more with PTMR than with medical care only. By 12 months there had been eight deaths in the PTMR group and three in the medical treatment group, with similar survival in the two groups.. PTMR was associated with increased exercise tolerance time, low morbidity, lower angina scores assessed by masked reviewers, and improved quality of life. Although there is controversy about the mechanism of action, and the contribution of the placebo effect cannot be quantified, this unmasked study suggests that this palliative procedure provides some clinical benefits in the defined population of patients.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Female; Follow-Up Studies; Humans; Laser Therapy; Male; Middle Aged; Myocardial Revascularization; Patient Dropouts; Survival Analysis; Survival Rate; Treatment Outcome

Transmyocardial revascularisation (TMR) is an operative treatment for refractory angina pectoris when bypass surgery or percutaneous transluminal angioplasty is not indicated. We did a prospective randomised trial to compare TMR with continued medication.. We recruited 182 patients from 16 US centres with Canadian Cardiovascular Society Angina (CCSA) score III (38%) or IV (62%), reversible ischaemia, and incomplete response to other therapies. Patients were randomly assigned TMR and continued medication (n=92) or continued medication alone (n=90). Baseline assessments were angina class, exercise tolerance, Seattle angina questionnaire for quality of life, and dipyridamole thallium stress test. We reassessed patients at 3 months, 6 months, and 12 months, with independent masked angina assessment at 12 months.. At 12 months, total exercise tolerance increased by a median of 65 s in the TMR group compared with a 46 s decrease in the medication-only group (p<0.0001, median difference 111 s). Independent CCSA score was II or lower in 47.8% in the TMR group compared with 14.3% in the medication-only group (p<0.001). Each Seattle angina questionnaire index increased in the TMR group significantly more than in the medication-only group (p<0.001).. TMR lowered angina scores, increased exercise tolerance time, and improved patients' perceptions of quality of life. This operative treatment provided clinical benefits in patients with no other therapeutic options.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Cause of Death; Exercise Test; Female; Follow-Up Studies; Humans; Laser Therapy; Male; Middle Aged; Myocardial Revascularization; Outcome and Process Assessment, Health Care; Prospective Studies; Quality of Life; Survival Rate

Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society).. In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients).. After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan-Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05); quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning.. Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Coronary Circulation; Disease-Free Survival; Exercise Tolerance; Female; Humans; Laser Therapy; Male; Middle Aged; Myocardial Revascularization; Postoperative Complications; Prospective Studies; Quality of Life; Severity of Illness Index; Survival Analysis

Topics: Angina Pectoris; Antioxidants; Cardiovascular Agents; Coenzymes; Cytoprotection; Female; Heart; Humans; Lipid Peroxidation; Male; Middle Aged; Myocardial Ischemia; Myocardium; Physical Exertion; Time Factors; Ubiquinone

To compare clinical and functional status in patients who had similar 5-year survival after coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA).. Randomized trial of 1829 patients followed for an average 5.4 years.. Patients with multivessel coronary artery disease suitable for both CABG and PTCA and not previously revascularized.. Coronary artery bypass grafting or PTCA within 2 weeks after randomization.. Symptoms, exercise test results, medication use, and quality-of-life measures collected at 4 to 14 weeks, and at 1, 3, and 5 years after randomization.. Intention to treat.. Differences in angina-free rates between patients assigned to PTCA and CABG decreased from 73% vs 95% at 4 to 14 weeks (P<.001) to 79% vs 85% at 5 years (P=.007). Similar patterns were observed for exercise-induced angina and ischemia, except 5-year differences were not significant. At follow-up of 1 year and later, quality of life, return to work, modification of smoking and exercise behaviors, and cholesterol levels were similar for the 2 treatments. Compared with patients assigned to CABG, use of anti-ischemic medication was higher in patients assigned to PTCA, while smaller differences were observed for other medications. Among patients angina-free at 5 years, 52% of patients who had PTCA required revascularization after the initial procedure vs 6% of patients who had CABG.. The narrowing of treatment differences in angina and exercise-induced ischemia rates can be attributed to a return of symptoms among patients assigned to CABG and incremental surgical procedures among patients assigned to PTCA. Patients assigned to PTCA apparently were able to tolerate higher rates of residual ischemia as evidenced by comparable quality of life and 5-year survival.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Exercise Test; Female; Heart Function Tests; Humans; Male; Middle Aged; Myocardial Infarction; Outcome and Process Assessment, Health Care; Quality of Life; Risk Factors; Survival Rate; United States

We hypothesized that among the patients enrolled in the Asymptomatic Cardiac Ischemia Pilot (ACIP) trial, those who reported angina either within the previous 6 weeks or experienced angina during ambulatory electrocardiographic (ECG) monitoring during activities of daily life or during stress testing would be more likely to experience an adverse cardiac event within a year than those who did not experience angina. Of the 558 patients enrolled in ACIP, 325 (58.2%) reported angina in the previous 6 weeks, 300 (53.8%) had stress-induced angina, and 63 (11.3%) reported angina during activities of daily life associated with ST-segment changes on the 48-hour ambulatory electrocardiogram. Some patients had > 1 of these angina symptoms and thus 8 angina status categories were identified. Adverse cardiac events were defined as death, nonfatal myocardial infarction (MI), or hospitalization for ischemic events, which included revascularization not specified by the ACIP protocol. One hundred and sixty-seven patients (29.9%) were asymptomatic (i.e., they never had angina) by our defined criteria. Three hundred ninety-one patients (70.1%) were symptomatic. Symptomatic patients had a higher incidence of death, MI, or hospitalization for ischemic events (15.3% symptomatic vs 7.8% asymptomatic, p = 0.016). History of angina within 6 weeks before randomization was predictive of death, MI, or hospitalization for ischemic event (p = 0.007). This finding was due to a large difference in the need for hospitalizations which would be expected to be driven by the presence of angina. By contrast, angina during ambulatory electrocardiogram or stress test was not predictive of an adverse cardiac event. The asymptomatic status of coronary disease patients who have objective documentation of ischemia is not uniformly defined and many different categories can be identified. In this population of patients with proven coronary artery disease and myocardial ischemia, a history of angina in the previous 6 weeks was a good predictor of an adverse event occurring in the next year.

Topics: Angina Pectoris; Cardiovascular Agents; Death, Sudden, Cardiac; Electrocardiography, Ambulatory; Follow-Up Studies; Hospitalization; Humans; Incidence; Life Tables; Myocardial Infarction; Myocardial Ischemia; Myocardial Revascularization; Pilot Projects; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Time Factors

The role of percutaneous transluminal coronary angioplasty (PTCA) in the management of patients with angina remains controversial, particularly in patients whose symptoms are adequately controlled by medical treatment.. RITA-2 is a randomised trial comparing the long-term effects of PTCA and conservative (medical) care in patients with coronary artery disease considered suitable for either treatment option. 1018 patients were recruited from 20 cardiology centres in UK and Ireland. The 504 randomised to PTCA were intended to have dilatation within 3 months. The 514 assigned to medical treatment received antianginal drugs; those whose symptoms were not controlled by optimum medical therapy could cross-over to myocardial revascularisation. The primary endpoint was the combined frequency of death from all causes and definite non-fatal myocardial infarction.. This report covers a median 2-7 years' follow-up. At randomisation 53% of patients had grade 2 or worse angina, and 40% had two or more diseased coronary arteries. 93% of patients randomised to PTCA had this procedure carried out, within a median of 5 weeks. Death or definite myocardial infarction occurred in 32 patients (6.3%) treated with PTCA and in 17 patients (3.3%) with medical care (absolute difference 3.0% [95% CI 0.4-5.7%]. p = 0.02). This difference was mainly due to one death and seven non-fatal myocardial infarctions related to the randomised procedures. There were 18 deaths (11 PTCA, seven medical) of which ten were not due to heart disease. Of the patients in the PTCA group, 40 (7.9%) required coronary artery bypass grafting (CABG), including nine instead of PTCA and seven emergencies following unsuccessful PTCA. 56 other PTCA patients (11.1%) required further non-randomised PTCA. In the medical group 118 patients (23.0%) underwent a revascularisation procedure during follow-up, mostly because of worsening symptoms. Angina improved in both groups, but more so in the PTCA group. There was a 16.5% absolute excess of grade 2 or worse angina in the medical group 3 months after randomisation (p < 0.001), which attenuated to 7.6% after 2 years. Total exercise time (Bruce protocol) also improved in both groups, again with a treatment difference in favour of PTCA: mean advantage of 35 s at 3 months (p < 0.001). These benefits of PTCA were greater in patients with more severe angina at baseline, judged by high initial grade of angina and short initial exercise-time.. In patients with coronary artery disease considered suitable for either PTCA or medical care, early intervention with PTCA was associated with greater symptomatic improvement, especially in patients with more severe angina. When managing individuals with angina, clinicians must balance these benefits against the small excess hazard associated with PTCA due to procedure-related complications.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Cause of Death; Coronary Artery Bypass; Exercise Test; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Infarction; Severity of Illness Index; Treatment Outcome

L-propionylcarnitine, a naturally occurring derivative of L-carnitine, essential for mitochondrial fatty acid transport and high-energy phosphate exchange, acutely reduces myocardial ischaemia and improves ischaemia-induced cardiac dysfunction following intravenous administration. This randomized, crossover study was designed to compare the long-term anti-ischaemic effects of oral L-propionylcarnitine with diltiazem in patients with stable, exercise-induced angina. After a 2-week washout phase of anti-anginal medication and a 2-week single-blind placebo period, 46 patients were included in the study, 23 of whom received 1500 mg L-propionylcarnitine daily for 6 weeks, and 23 diltiazem (180 mg daily for 3 weeks, followed by 360 mg daily for 3 weeks), crossing over to the other treatment after a 1-week washout period. Three patients on L-propionylcarnitine and two on diltiazem discontinued. Both treatments resulted in comparable exercise duration (582 +/- 35 s and 588 +/- 33 s, mean +/- SEM), time to 0.1 mV ST depression (436 +/- 38 s and 465 +/- 36 s), and increase in time to 0.1 mV ST depression from baseline (20% and 28%), L-propionylcarnitine and diltiazem, respectively. Diltiazem decreased the rate-pressure product at rest and exercise, L-propionylcarnitine did not. Both compounds significantly reduced ST depression at maximal exercise [23% (L-propionylcarnitine) vs 35% (diltiazem), P < 0.05 diltiazem vs L-propionylcarnitine]. Diltiazem increased the time to onset of angina by 22%. In contrast, no significant changes occurred with L-propionylcarnitine. During the study, anginal attacks were reduced by 70% and 57%, and nitroglycerin consumption decreased by 57% and 70%, L-propionylcarnitine and diltiazem, respectively. Thus, both L-propionylcarnitine and (high-dose) diltiazem result in anti-ischaemic effects and decrease anginal attacks in daily life. Although the effect of diltiazem on exercise-induced ischaemia appears more pronounced than that of L-propionylcarnitine, this novel metabolic approach to ischaemia warrants further development.

Topics: Adult; Aged; Angina Pectoris; Blood Pressure; Cardiotonic Agents; Cardiovascular Agents; Carnitine; Cross-Over Studies; Diltiazem; Double-Blind Method; Electrocardiography, Ambulatory; Exercise Test; Female; Heart Rate; Humans; Male; Middle Aged; Treatment Outcome

Lipid-lowering therapy reduces cardiac morbidity and mortality. Less is known about its potential anti-ischemic effect.. In a 2-year prospective randomized placebo-controlled study, the effect of pravastatin 40 mg on transient myocardial ischemia was assessed. Forty-eight-hour ambulatory ECGs with continuous ST-segment analysis were performed in 768 male patients with stable angina pectoris, documented coronary artery disease, and serum cholesterol between 4 and 8 mmol/L (155 and 310 mg/dL). During the trial, patients received routine antianginal treatment. In the patients randomized to pravastatin, transient myocardial ischemia was present at baseline in 28% and after treatment in 19%; in the placebo group, it was found in 20% and 23% of the patients, respectively (P = .021 for change in percentage between two treatment groups; odds ratio, 0.62; 95% CI, 0.41 to 0.93). Ischemic episodes decreased by 1.23 +/- 0.25 (SEM) episode with pravastatin and by 0.53 +/- 0.25 episode with placebo (P = .047). Under pravastatin, the duration of ischemia decreased from 80 +/- 12 minutes to 42 +/- 10 minutes (P = .017) and with placebo, from 60 +/- 13 minutes to 51 +/- 9 minutes (P = .56). The total ischemic burden decreased from 41 +/- 5 to 22 +/- 5 mm.min in the pravastatin group (P = .0058) and from 34 +/- 6 to 26 +/- 4 mm . min in the placebo group (P = .24). Adjusted for independent risk factors for the occurrence of ischemia, the effect of pravastatin on the reduction of risk for ischemia remained statistically significant (odds ratio, 0.45; 95% CI, 0.22 to 0.91; P = .026).. In men with documented coronary artery disease and optimal antianginal therapy, pravastatin reduces transient myocardial ischemia.

Topics: Angina Pectoris; Anticholesteremic Agents; Cardiovascular Agents; Cholesterol; Drug Therapy, Combination; Electrocardiography, Ambulatory; Humans; Male; Middle Aged; Myocardial Ischemia; Pravastatin; Prospective Studies

A simple stress/redistribution thallium-201 myocardial perfusion imaging protocol may underestimate the degree of thallium redistribution in a defect identified on the stress images. We sought to investigate whether a slow-bolus injection of D-ribose improves the identification of thallium redistribution following combined adenosine/dynamic exercise stress.. Fifteen patients (10 males, five female, median age 63 years, range 50-75) were enrolled in the study. All underwent two successive adenosine plus exercise myocardial perfusion scintigraphy protocols 7-14 days apart. Adenosine was infused at 140 micrograms.kg-1.min-1 coupled with 25 W ergometer pedalling for 6 min with 74 Mbq of thallium-201 being injected at 4 min. Immediately following the stress image acquisition, patients received the one of either 60 mg.kg-1 of D-ribose or normal saline, injected over 5 min. Redistribution images were acquired after 4 h. The identical stress procedure was conducted in the crossover arm of the study, and patients received the alternative test article. SPECT images were visually analysed and scored in a nine segment model by two blinded observers. In addition, circumferential profile analysis was conducted.. By visual interpretation 25 segments displayed redistribution of the ribose, but not in the saline study, 14 reversible segments were seen on the saline study alone and 18 were seen on both studies (P = ns). In six patients ribose identified a greater number of redistributing segments and in a further six patients saline identified more reversible segments. Comparison of mean values of defect extent severity and percentage reversibility scores generated from the circumferential profile analysis showed no significant difference between the two arms of the study.. A 5 min bolus injection of D-ribose following combined adenosine/dynamic exercise stress confers little benefit on the identification of redistribution of thallium-201. These results differ from those of previous studies which showed that a 30 min infusion of D-ribose following treadmill exercise significantly enhanced thallium redistribution. The duration of the ribose infusion is likely to be an important factor influencing the effect brought to bear on the redistribution of the tracer, and should be run over 30 min, or longer.

Topics: Adenosine; Aged; Angina Pectoris; Cardiovascular Agents; Chi-Square Distribution; Cross-Over Studies; Double-Blind Method; Exercise Test; Female; Hemodynamics; Humans; Infusions, Intravenous; Isotopes; Male; Middle Aged; Prospective Studies; Radionuclide Imaging; Ribose; Thallium

This pilot study demonstrated that (1) patients with CAD and asymptomatic cardiac ischemia can be randomized to medical or revascularization strategies using a complex and demanding protocol, (2) asymptomatic cardiac ischemia can be suppressed in 40-50% of patients with clinically advanced coronary disease with relatively low to moderate doses of medication titrated over a period of 12 weeks (3). Revascularization was the most effective of the treatment strategies studied in reducing ischemia. Any type of therapy, whether it be drugs or revascularization requiring repetitive monitoring with ambulatory ECG or other methods to detect ischemia over a long period of time, will escalate the cost of quality medical care for our patients. Thus, the health care costs implications and treatment of asymptomatic ischemia are enormous. But the apparent cost advantage of treating only symptoms, that is ignoring all ischemia, could disappear if treatment of ischemia reduces the risk of adverse events. The clinical question to be addressed in the future is what is necessary to reduce the cardiac-event rates of death and myocardial infarction in this group of patients? Will more aggressive drug therapy eliminate more ischemia and will therapy directed at the elimination of all detectable ischemia improved clinical outcome better than therapy directed to control angina only? These questions can only be answered by a large clinical trial. The results of such a trial will provide the basis and rationale for safe and effective therapy for patients with coronary disease and evidence of cardiac ischemia. Whatever the answer to this important medical and scientific question is, it will have tremendous economic implications.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Angina Pectoris; Angioplasty; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Electrocardiography, Ambulatory; Exercise Test; Female; Humans; Male; Middle Aged; Myocardial Ischemia; Prognosis

We examined the antianginal and anti-ischemic effects of oral zatebradine, a direct sinus node inhibitor that has no blood pressure-lowering or negative inotropic effects in patients with chronic stable angina pectoris taking extended-release nifedipine.. Heart rate reduction is considered an important pharmacologic mechanism for providing anginal pain relief and anti-ischemic action in patients with chronic stable angina, suggesting a benefit for sinus node-inhibiting drugs.. In a single-blind placebo run-in, randomized double-blind, placebo-controlled, multicenter study, patients already receiving extended-release nifedipine (30 to 90 mg once a day) were randomized to receive zatebradine (5 mg twice a day [n = 64]) or placebo (n = 60). All subjects had reproducible treadmill exercise-induced angina at baseline, and after randomization they performed a serial exercise test 3 h after each dose for 4 weeks.. Zatebradine reduced rest heart rate both at 4 weeks ([mean +/- SEM] 12.9 +/- 1.23 vs. 2.3 +/- 1.6 [placebo] beats/min, p < 0.0001) and at the end of comparable stages of Bruce exercise (16.7 +/- 1.2 vs. 3.4 +/- 1.2 [placebo] beats/min, p < 0.0001). Despite the significant effects on heart rate at rest and exercise, there were no additional benefits of zatebradine from placebo baseline in measurements of total exercise duration, time to 1-mm ST segment depression or time to onset of angina. Subjects taking zatebradine also had more visual disturbances as adverse reactions.. Zatebradine seems to provide no additional antianginal benefit to patients already receiving nifedipine, and it raises questions regarding the benefit of heart rate reduction alone as an antianginal approach to patients with chronic stable angina.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Benzazepines; Blood Pressure; Cardiovascular Agents; Chronic Disease; Delayed-Action Preparations; Double-Blind Method; Drug Therapy, Combination; Exercise Test; Female; Heart Rate; Humans; Male; Middle Aged; Nifedipine; Treatment Outcome

The Asymptomatic Cardiac Ischemia Pilot (ACIP) study showed that revascularization is more effective than medical therapy in suppressing cardiac ischemia at 12 weeks. This report compares the relative efficacy of coronary angioplasty or coronary artery bypass graft surgery in suppressing ambulatory electrocardiographic (ECG) and treadmill exercise cardiac ischemia between 2 and 3 months after revascularization in the ACIP study.. Previous studies have shown that coronary angioplasty and bypass surgery relieve angina early after the procedure in a high proportion of selected patients. However, alleviation of ischemia on the ambulatory ECG and treadmill exercise test have not been adequately studied prospectively after revascularization.. In patients randomly assigned to revascularization in the ACIP study, the choice of coronary angioplasty or bypass surgery was made by the clinical unit staff and the patient.. Patients assigned to bypass surgery (n = 78) had more severe coronary disease (p = 0.001) and more ischemic episodes (p = 0.01) at baseline than those assigned to angioplasty (n = 92). Ambulatory ECG ischemia was no longer present 8 weeks after revascularization (12 weeks after enrollment) in 70% of the bypass surgery group versus 46% of the angioplasty group (p = 0.002). ST segment depression on the exercise ECG was no longer present in 46% of the bypass surgery group versus 23% of the angioplasty group (p = 0.005). Total exercise time in minutes on the treadmill exercise test increased by 2.4 min after bypass surgery and by 1.4 min after angioplasty (p = 0.02). Only 10% of the bypass surgery group versus 32% of the angioplasty group still reported angina in the 4 weeks before the 12-week visit (p = 0.001).. Angina and ambulatory ECG ischemia are relieved in a high proportion of patients early after revascularization. However, ischemia can still be induced on the treadmill exercise test, albeit at higher levels of exercise, in many patients. Bypass surgery was superior to coronary angioplasty in suppressing cardiac ischemia despite the finding that patients who underwent bypass surgery had more severe coronary artery disease.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Drug Therapy, Combination; Electrocardiography, Ambulatory; Exercise Test; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Ischemia; Pilot Projects; Prospective Studies; Recurrence; Remission Induction; Time Factors; Treatment Outcome

Topics: Age Factors; Aged; Aged, 80 and over; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Diltiazem; Female; Hemodynamics; Humans; Male; Middle Aged; Nifedipine; Outpatients; Vasodilator Agents; Verapamil

To characterize a contemporary, nonhospitalized population with angina pectoris, data were obtained from a geographically diverse cohort of 5,125 outpatients with chronic stable angina cared for by 1,266 primary care physicians between September and November of 1990. Diagnosis was based on history supported by evidence for coronary artery disease (coronary angiography, old myocardial infarction, or an abnormal stress test, either alone or in combination). The mean age of the patients was 69 years and 53% were women. Seventy percent had > 1 associated illness and 64% took > 1 cardiovascular drug. Median angina frequency was approximately 2 episodes/week and increased angina frequency (p < 0.0001) was associated with decreased overall feeling of well-being. Although effort angina was present in 90% of patients, 47% also had rest angina and 35% had mental stress-evoked angina. Female gender (relative risk [RR] 1.09; 95% confidence interval [CI] 1.02 to 1.16), concomitant illness (RR 1.17; CI 1.09 to 1.25), and pharmacotherapy (RR 1.14; CI 1.07 to 1.22) were associated with excess risk for rest angina. Younger age (RR 1.30; CI 1.20 to 1.41), female gender (RR 1.16; CI 1.07 to 1.26), concomitant illness (RR 1.13; CI 1.03 to 1.24), and pharmacotherapy (RR 1.28; CI 1.15 to 1.93) were associated with excess risk for mental stress angina. These data suggest that contemporary outpatients with angina are frequently women and elderly patients with high rates of associated illness, rest, and mental stress-related angina.

Topics: Administration, Cutaneous; Aged; Angina Pectoris; Cardiovascular Agents; Cardiovascular Diseases; Cohort Studies; Drug Therapy, Combination; Female; Humans; Male; Middle Aged; Nitrates; Prospective Studies; Quality of Life

The Randomised Intervention Treatment of Angina (RITA) trial is comparing the long-term effects of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) in patients with one, two, or three diseased coronary arteries in whom equivalent revascularisation was deemed achievable by either procedure. This first report is for a mean 2.5 years' follow-up on the 1011 patients randomised. 59% had grade 3 or 4 angina, 59% had experienced angina at rest, and 55% had two or more diseased coronary arteries. The intended procedure was done in 98% of patients. In 97% of CABG patients all intended vessels were grafted. Dilatation of all treatment vessels was attempted in 87% of PTCA patients with an angiographic success rate per vessel of 87% (90% excluding occluded vessels). There have been 34 deaths (18 CABG, 16 PTCA) and the pre-defined combined primary event of death or definite myocardial infarction shows no evidence of a treatment difference (43 CABG, 50 PTCA; relative risk 0.88 [95% confidence interval 0.59-1.29]). 4% of PTCA patients required emergency CABG before discharge and a further 15% had CABG during follow-up. Within 2 years of randomisation 38% and 11% of the PTCA and CABG groups, respectively, required revascularisation procedure(s) or had a primary event (p < 0.001) and repeat coronary arteriography during follow-up was four times more common in PTCA than in CABG patients (31% vs 7%, p < 0.001). The prevalence of angina during follow-up was higher in the PTCA group (eg, 32% vs 11% at 6 months) but this difference became less marked after 2 years (31% vs 22%). Anti-anginal drugs were prescribed more frequently for PTCA patients. At 1 month CABG patients were less physically active, with greater coronary related unemployment and lower mean exercise times than the PTCA patients. Thereafter employment status, breathlessness, and physical activity improved, with no significant differences between the two treatment groups. At 1 year mean exercise times had increased by 3 min for both groups. These interim findings indicate that recovery after CABG, the more invasive procedure, takes longer than after PTCA. However, CABG leads to less risk of angina and fewer additional diagnostic and therapeutic interventions in the first 2 years than PTCA. So far, there is no significant difference in risk of death or myocardial infarction, and follow-up continues to at least five years.

Topics: Adult; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Employment; England; Exercise; Exercise Test; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Prevalence; Recurrence; Reoperation; Severity of Illness Index; Stroke Volume; Survival Rate; Treatment Outcome; Wales

Patients with chronic coronary artery disease exhibit a dysfunctioning endothelium, which may be responsible for exercise-induced platelet activation and expression of a procoagulant moiety. In this study, we evaluated the therapeutic efficacy of a low molecular weight heparin (Parnaparin) in patients with stable angina pectoris.. According to a double-blind, randomized, placebo-controlled trial, 29 patients with stable exercise-induced angina pectoris and angiographically proven coronary artery disease received a single daily subcutaneous injection of Parnaparin or placebo on top of aspirin and conventional antianginal medication over 3 months. Patients randomized to Parnaparin showed a significant decrease in the fibrinogen level (P = .035) and an improvement in both the time to 1-mm ST segment depression (P = .008) and the peak ST segment depression (P = .015). The Canadian Cardiovascular Society class for angina pectoris was also improved by Parnaparin (P = .016). Parnaparin did not affect ADP and collagen-induced platelet aggregation, whereas thrombin-induced aggregation was reduced (P = .0001). The bleeding time was slightly prolonged, but this was not associated with any significant bleeding.. Patients with stable angina pectoris may be treated with Parnaparin in addition to aspirin and conventional antianginal medication. Side effects are negligible, and compliance is excellent.

Topics: Adult; Aged; Angina Pectoris; Bleeding Time; Cardiovascular Agents; Double-Blind Method; Drug Therapy, Combination; Exercise Test; Female; Fibrinogen; Heparin, Low-Molecular-Weight; Humans; In Vitro Techniques; Male; Middle Aged; Platelet Aggregation

The study covered 20 patients with angina pectoris. Antianginal drugs such as sydnopharm, kordafen, anaprilin, nitrosorbide, and foridon were tested by using pair exercise tests. All the patients had preliminary instrumental studies, including exercise test, echocardiography, hyperventilation and orthostatic tests, and variation pulsometry. A regression equation was derived, which could predict the efficacy of foridon from the findings of the tests used. The antianginal effect of foridon was found to be the weakest among the other drugs under study.

Topics: Angina Pectoris; Blood Pressure; Cardiovascular Agents; Echocardiography; Exercise Test; Heart Rate; Humans; Male; Middle Aged; Nifedipine; Prognosis; Respiratory Function Tests

Altogether 359 paired bicycle ergometries coupled with administration of single doses of antianginal drugs were carried out in 62 men suffering from angina pectoris of effort, functional classes II and III. A study was made of the indicator characterizing the time that elapsed since the onset of a typical angina pectoris attack till the appearance of the signs of ischemia on the ECG. Administration of effective single doses of antianginal drugs raised the time elapsed since the pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall during the exercise. Administration of ineffective doses of nitrates, calcium antagonists and placebo entailed a decline of that indicator, a rise of the number of cases where the segment ST greater than or equal to 1.0 mm fall was recordable before the onset of painful sensations. Administration of propranolol in ineffective single doses failed to provoke a decrease of the time elapsed since the typical pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall. Intake of ineffective single doses of nitrates, calcium antagonists and placebo may deprive certain patients of early signalization and appearance of the ECG signs of myocardial ischemia.

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Dose-Response Relationship, Drug; Electrocardiography; Exercise Test; Humans; Male; Middle Aged; Physical Exertion; Placebos; Time Factors

The extent to which posture altered the haemodynamic response to slow calcium channel blocker nicardipine was evaluated in 22 male patients with angiographically confirmed coronary artery disease. Patients were randomly allocated to supine or upright posture and an otherwise identical protocol performed in each group. At rest, following a control saline period, four doses of the drug (log cumulative dosage: 1.25, 2.5, 5.0, and 10.0 mg) were administered by i.v. infusion over a total period of 40 min; haemodynamic indices were recorded during the 3-5 min following each 5 min infusion. The exercise effects of the drug, in each posture, were determined by comparison of a control predrug exercise with observations at the same workload following the maximal cumulative dose. Nicardipine reduced resting mean blood pressure (MBP) and systemic vascular resistance index (SVRI) in both postures, the decrease being more pronounced when upright (MBP, -12%, -18%; p less than 0.01: SVRI, -30%, -46%; p less than 0.01). The increases in cardiac index (CI) and stroke volume index (SVI) were higher when upright (29 and 54% vs. 10 and 27%; p less than 0.01). Pulmonary artery occluded pressure (PAOP) increased by 29% when upright, without change when supine. On exercise, the effects for HR, MBP, CI, SI, and SVRI responses were independent of posture; however, a qualitative difference was apparent for PAOP (-17% vs. +14%; p less than 0.05). Thus, although the actions of nicardipine were qualitatively similar, quantitative differences related to posture were confirmed. These differences appeared to relate to posture-related baseline haemodynamic differences between the groups but with similar postnicardipine absolute values.

Topics: Adult; Aged; Angina Pectoris; Blood Pressure; Cardiac Output; Cardiovascular Agents; Coronary Disease; Dose-Response Relationship, Drug; Exercise; Heart Rate; Hemodynamics; Humans; Male; Middle Aged; Nicardipine; Posture; Pulmonary Circulation; Vascular Resistance

The present study has been performed to assess the effects of alinidine on diastolic duration during exercise in chronic coronary artery disease. Twelve male patients with stable effort angina and without previous myocardial infarction were studied. They received alinidine or placebo in a double-blind randomized crossover trial for 3 days after a wash-out period of 4 days. Alinidine was administered at a dosage of 30 mg 3 times a day. At the end of each treatment the patients underwent upright bicycle exercise. Left ventricular time intervals were obtained by means of carotid thermistor plethysmography. Diastolic duration was calculated by subtracting the electromechanical systole from the R-R interval and expressed as a percentage of the cardiac cycle (%D). Alinidine increased both total exercise duration from 246.7 +/- 120.7 to 346.6 +/- 114.1 s (p less than 0.05) and time to 0.1-mV ST segment depression from 98.3 +/- 53 to 187.2 +/- 105 s (p less than 0.05). Similarly the drug induced a reduction of the rate-pressure product and of the extent of ischemic ST segment depression during exercise. %D was increased by alinidine both at rest and during exercise. A direct linear regression between R-R and %D was found after both alinidine and placebo treatments either at rest or during exercise. Nevertheless, no difference was observed between both slopes and intercepts. Therefore, since the relationship between R-R interval and %D was unaffected by alinidine, it was possible to hypothesize that the changes in diastolic duration were due only to the bradycardic action of the drug.

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Clonidine; Diastole; Double-Blind Method; Exercise Test; Humans; Male

Constriction of atherosclerotic coronary segments during exercise may further reduce coronary flow reserve in patients with coronary artery disease. This could influence the linear regression analysis of the heart rate-related changes in ST-segment depression (ST/HR slope) thereby limiting the accuracy of this method in identifying the severity of the disease. To test this hypothesis, the exercise related ST/HR slopes on placebo were compared with those obtained during coronary vasodilation induced by a prostacyclin analogue (iloprost 6 ng kg-1 min-1) in 42 anginal patients with documented coronary artery disease. In seven of these, the same protocol was repeated during right heart catheterization. The overall diagnostic accuracy of the ST/HR slope on iloprost was better than on placebo in patients with advanced coronary artery disease. This was due mainly to a consistent rightward shift of the ST/HR slope in patients with one- and two-vessel, but not three-vessel disease or left main stem disease. The reason for the greater effects of iloprost on ST/HR slopes in patients with a lesser degree of atherosclerosis remains unclear. However, coronary blood flow was higher during drug infusion, which suggests that iloprost may prevent the occurrence of dynamic coronary events able to reduce the maximum coronary flow reserve during exertion. This mechanism may be predominant in patients with minor coronary artery disease.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Coronary Artery Disease; Coronary Circulation; Coronary Disease; Electrocardiography; Epoprostenol; Exercise Test; Female; Heart Rate; Humans; Iloprost; Male; Middle Aged; Single-Blind Method

Against placebo background 50 patients with effort stenocardia received mildronate, a new native cardioactive drug and its effects on the clinical course in conditions of spirometric bicycle ergometry were studied. It was found that monotherapy with mildronate is accompanied by an antianginal effect and an increase of the physical working capacity of patients.

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Exercise Test; Humans; Male; Methylhydrazines; Middle Aged; Physical Endurance; Randomized Controlled Trials as Topic; Spirometry

The effect of a chemically stable prostacyclin analogue (Iloprost) on platelet function was investigated in a controlled study in patients with angiographically confirmed stable angina pectoris after ischaemic exercise. In placebo experiments, ADP platelet aggregation was increased after exercise only when measured in whole blood and not in PRP. While plasma thromboxane B2 levels were unchanged, those of 6-keto PGF1 alpha were significantly although transiently increased after exercise. Iloprost displayed a potent antiaggregating activity in PRP and also reversed platelet hyperaggregation occurring in whole blood determinations after exercise. Plasma thromboxane B2 levels were significantly reduced but occasionally a rebound increase occurred 30 min. after end of the infusion. In contrast plasma level of 6-keto PGF1 alpha did not change after Iloprost and its recorded post-exercise increase was counteracted, thus suggesting a negative feed-back mechanism between Iloprost and natural prostacyclin. The data also suggest that degradation of the analogue is probably accomplished through pathways different from those of PGI2.

Topics: 6-Ketoprostaglandin F1 alpha; Aged; Angina Pectoris; Blood Platelets; Cardiovascular Agents; Coronary Disease; Epoprostenol; Humans; Iloprost; Male; Middle Aged; Physical Exertion; Platelet Aggregation; Platelet Function Tests; Random Allocation; Thromboxane B2

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Clinical Trials as Topic; Dose-Response Relationship, Drug; Drug Evaluation; Humans; Placebos

The effects of iloprost, a chemically stable compound with prostacyclin mimetic activity, on exercise capacity and platelet aggregation were assessed in 24 patients with effort angina and proved critical (at least 70% diameter narrowing) coronary artery disease. Upright bicycle ergometer testing (25-W increments every 2 minutes) was performed during drug and placebo infusions using a crossover, randomized, single-blind protocol. Samples for measurements of adenosine diphosphate-induced platelet aggregation in platelet-rich plasma were obtained in all patients before and during the study. Compared with placebo, intravenous iloprost consistently (p less than 0.001) prolonged exercise duration and time to onset of significant (0.1 mV) ST depression. Angina and ST depression occurred at a greater heart rate and rate-pressure product. Benefits were remarkable in some patients (67%) and not in others. Iloprost administration resulted in reduced platelet aggregation at peak exercise in all patients, whether they had consistent or little response to the drug. Thus, iloprost administration may improve exercise capacity in patients with stable exertional angina pectoris. Improvements are independent of changes in the major determinants of myocardial oxygen demand and associated with markedly reduced platelet aggregation, which may account for increased myocardial perfusion in patients with high sensitivity to coronary constriction.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Electrocardiography; Epoprostenol; Exercise Test; Female; Humans; Iloprost; Male; Middle Aged; Pain; Platelet Aggregation; Random Allocation

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Exercise Test; Humans; Male; Middle Aged; Nifedipine; Nitroglycerin; Ointments; Propranolol; Vasodilator Agents; Verapamil

This is the first report of the use of DHM 32-550 a dehydrogenated peptide ergot alkaloid with both alpha and beta adrenoceptor blocking activity, in patients with angina-like chest pain. Five patients were studied to assess a dose/response relationship. No deleterious effects on blood pressure occurred at either rest or on effort. The frequency of angina attacks and the number of glyceryl trinitrate tablets needed per week was appreciably reduced during treatment with both 'high' and 'low' dosages of the agent compared with placebo. The duration of treadmill exercise was appreciably prolonged. Within the limitations of this small, open pilot study, it appears that oral DHM 32-550 could be used safely in patients with chest pain due to cardiomyopathy or to coronary spasm.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Dose-Response Relationship, Drug; Electrocardiography; Ergot Alkaloids; Exercise Test; Female; Hemodynamics; Humans; Male; Middle Aged; Nitroglycerin; Pilot Projects

Topics: Aged; Angina Pectoris; Blood Pressure; Cardiovascular Agents; Clinical Trials as Topic; Clonidine; Double-Blind Method; Electrocardiography; Heart Rate; Humans; Male; Middle Aged; Physical Exertion

The therapeutic effect of obsidan (25 to 250 mg/24 h), cordanum (75 to 300 mg/24 h), nitropenton (30 mg/24 h), combination of obsidan with nitropenton, prenylamin (180 mg/24 h), stenopril (180 mg/24 h), cordaron (600 mg/24h) and corvaton (4 mg/24 h) was studied according to clinical asessment in 127 patients with stenocardia and in 44 of them by loading tests (veloergometry or treadmill). According to the clinical assessment -- very good (abating of stenocardia paroxysms) and good effect (less frequent paroxysms nitroglycerin necessary every one-two days) was established in 82 per cent of those treated with obsidan, in 78 per cent of the treated with cordanum, in 86 per cent of those treated with the combination obsidan with nitropenton, in 44 per cent of the treated with nitropenton, in 42 per cent of the treated with prenylamin, in 46 per cent pf the treated with stenopril, in 7 out of 9 patients treated with cordaron as well as in 7 out of 9 patients treated with corvaton. According to the data from the loading tests--very good (increase of capacity, not limited by pain and ST depression) and good effect (considerable increase of capacity but limited by pain and ST depression) was found in 77 per cent of the patients administered obsidan, in 67 per cent of those administered cardanum and in 33 per cent of the patients administered tenopril and prenylamin. Beta--blockers significantly excel the therapeutic effect of stenopril, prenylanin and nitropenton, both according to clinical assessment (P < 0,02 to p < 0,001) and to the data from the loading tests (P < 0,02). Beta-blockers dosage was individually determined but 80 per cent of the patients with a favourable effect by obsidan or cordanum had received 60-120 mg/24 h and 150 mg/24 h respectively. The individual effect of the patients is presented so that even the small number of cases observed with cordaron and corvaton treatment shows it reasonable to include new preparations in antianginose treatment.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Drug Therapy, Combination; Female; Humans; Male; Middle Aged

Angina pectoris (AP) is the initial and the most common manifestation of coronary artery disease (CAD). Therefore, management and control of AP can help prevent further complications associated with CAD. However, there is under-reporting of angina symptoms in clinical practice, resulting in under-treatment and reduced quality of life (QoL). Prospective and standardized monitoring is needed to support timely and appropriate treatment.. To establish a large cohort of Chinese patients with AP and compare the effectiveness of different anti-angina regimens with the help of electronic patient-reported outcomes (e-PROs), using the Seattle Angina Questionnaire (SAQ) to assess health status.. The registry study (GREAT) is a multicenter, prospective, observational, cohort study. Patients diagnosed with AP will be enrolled from 10 hospitals and assessed based on the different anti-anginal regimens. Patients will be followed up every 3 months from baseline to 12 months to observe the difference in the therapeutic effectiveness of the drugs. Data will be collected in the form of e-PROs combined with on-site visit records.. The change in SAQ summary score (SAQ SS) at Month 12 from baseline will be the primary outcome. The secondary measures will include changes in SAQ SS at Months 3, 6, and 9 from baseline, changes in retest results of vascular stenosis imaging at Month 12 from baseline, and medication adherence based on the proportion of days covered. Safety data will be evaluated based on the incidence of adverse events (AEs).. This study will evaluate the effectiveness of anti-anginal regimens using ePROs in real-world settings in China. The results from this study may provide a new perspective on treatment patterns and the effectiveness of different anti-anginal regimens for patients with AP.. NCT05050773.

Topics: Angina Pectoris; Cardiovascular Agents; Cohort Studies; Coronary Artery Disease; East Asian People; Humans; Multicenter Studies as Topic; Patient Reported Outcome Measures; Prospective Studies; Quality of Life; Treatment Outcome

To address the existing gaps in knowledge about long-acting nitroglycerine (LA-NTG) and provide recommendations to address these issues.. Approved LA-NTG questionnaire that included 17 questions related to the role of LA-NTG in the management of angina and chronic coronary syndrome (CCS) was shared with 150 expert cardiologists from different regions from India. Results of these survey questionnaires were further discussed in 12 regional level meetings. The opinions and suggestions from all the meetings were compiled and analyzed. Further, recommendations were made with the help of attending national cardiology experts and a consensus statement was derived.. This is the first consensus on LA-NTG, summarizing the clinical evidence from India and suggesting recommendations based on these data. The experts recommended early use of LA-NTG as a first-line antianginal therapy in combination with beta-blocker since it improves exercise tolerance in patients with CCS. A strong consensus was observed for using LA-NTG in patients with co-morbid hypertension, diabetes, chronic kidney disease and post-percutaneous coronary intervention angina. As a part of cardiac rehabilitation, LA-NTG allows patients with angina to exercise to a greater functional capacity.. A national consensus was observed for several aspects of LA-NTG in the management of angina and CCS. The clinical experience of the experts confirmed an extremely satisfied patient perception about the efficacy of LA-NTG.

Topics: Angina Pectoris; Cardiovascular Agents; Humans; India; Nitroglycerin; Percutaneous Coronary Intervention; Syndrome

Topics: Angina Pectoris; Angina, Stable; Cardiovascular Agents; Humans; Ranolazine; Treatment Outcome; Trimetazidine; Vasodilator Agents

Topics: Angina Pectoris; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cardiac Rehabilitation; Cardiovascular Agents; Cardiovascular Diseases; Combined Modality Therapy; Complementary Therapies; Coronary Angiography; Coronary Artery Disease; Coronary Stenosis; Drugs, Chinese Herbal; Humans; Male; Medicine, Chinese Traditional; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Stents; Stroke Volume; Syndrome; Tai Ji

Coronary artery anomalies are rare congenital variants of coronary artery anatomy accounting second most common cause of sudden cardiac death in young competitive athletes. A single ostium coronary artery anomalous is an extremely rare variant with an incidence of less than 0.004%. They may present as chest pain, arrhythmia, or sudden death. Recently, advanced imaging techniques such as computed tomography and magnetic resonance imaging coronary angiography are becoming the alternatives investigation for diagnosis. We reported a rare case of 50 years old lady who presented with acute chest pain with normal electrocardiography, echocardiography, and cardiac markers. Coronary Computed tomography angiography revealed anomalous coronary artery anatomy with both right and left coronary artery arising from the large common trunk of the right coronary cusp, left main coronary artery having trans-septal course, there was no flow-limiting coronary artery disease. She was medically managed with a single antiplatelet, beta-blocker, and statin therapy.

Topics: Administration, Oral; Adrenergic beta-Antagonists; Angina Pectoris; Biomarkers; Cardiovascular Agents; Computed Tomography Angiography; Coronary Angiography; Coronary Vessel Anomalies; Echocardiography; Electrocardiography; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Middle Aged; Platelet Aggregation Inhibitors

Kuanxiong aerosol has been reported to be an effective and safe clinical treatment for angina pectoris (AP).. To explore the potential pharmacological mechanism of Kuanxiong aerosol by combined methods of network pharmacology prediction and experimental verification.. Networks of Kuanxiong aerosol-associated targets and AP-related genes were constructed through STRING database. Potential targets and pathway enrichment analysis related to the therapeutic efficacy of Kuanxiong aerosol were identified using Cytoscape and Database for Annotation, Visualization and Integrated Discovery (DAVID). To explore the mechanism of action of Kuanxiong aerosol, its in vitro effects on myocardial hypoxia, inflammatory cytokines, and oxidative injury, and its in vivo pharmacological effects on myocardial ischemia and cardiac fibrosis were studied in rat models.. Network pharmacology analysis revealed that the potential targets mainly include the Fas ligand (FASLG), interleukin 4 (IL4), and catalase (CAT), which mediated the processes of apoptosis, and cellular responses to hypoxia, lipopolysaccharide (LPS), reactive oxygen species (ROS), and mechanical stimulus. Multiple pathways, such as the hypoxia-inducible factor 1 (HIF1) and tumor necrosis factor (TNF) pathways were found to be closely related to the pharmacological protective mechanism of Kuanxiong aerosol against AP. In addition, Kuanxiong aerosol suppressed the hypoxia, LPS, and hydrogen peroxide (H. This study revealed that the pharmacological mechanisms of Kuanxiong aerosol for AP therapy were related to anti-myocardial ischemia, anti-inflammation, and anti-oxidation via a non-hemodynamic manner, indicating that Kuanxiong aerosol is a preferable drug clinically for AP treatment due to its both preventive and protective effects.

Topics: Administration, Sublingual; Aerosols; Angina Pectoris; Animals; Cardiovascular Agents; Cell Line; Databases, Genetic; Disease Models, Animal; Drug Combinations; Gene Expression Regulation; Gene Regulatory Networks; Male; Myocytes, Cardiac; Oils, Volatile; Protein Interaction Maps; Rats, Wistar; Signal Transduction; Systems Biology

Ranolazine is approved for patients with chronic stable angina but has not been formally studied in patients with refractory angina pectoris (RAP). Patients with RAP have limited therapeutic options and significant limitations in their quality of life. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness of ranolazine in RAP patients in order to expand treatment options for this challenging patient population. Using an extensive prospective database, we enrolled 158 consecutive patients evaluated in a dedicated RAP clinic. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 12, 24, and 36 months. At 3 years, 95 (60%) patients remained on ranolazine. A ≥2 class improvement in angina was seen in 48% (38 of 80 patients with known Canadian Cardiovascular Society class) of those who remained on ranolazine. Discontinuation due to side effects, ineffectiveness, cost, and progression of disease were the principle reasons for discontinuation, but primarily occurred within the first year. In conclusion, ranolazine is an effective antianginal therapy at 3-year follow-up in patients with RAP and may reduce cardiac readmission.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Constipation; Deprescriptions; Diabetes Mellitus; Disease Progression; Dizziness; Drug Costs; Dyslipidemias; Edema; Female; Humans; Hypertension; Male; Medication Adherence; Middle Aged; Mortality; Myocardial Infarction; Myocardial Revascularization; Nausea; Ranolazine; Registries; Smoking; Treatment Failure; Treatment Outcome

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Circulation; Female; Follow-Up Studies; Humans; Magnetic Resonance Imaging; Middle Aged; Myocardial Ischemia; Myocardial Perfusion Imaging; Prospective Studies; Recovery of Function; Risk Assessment; Risk Factors; Sex Factors; Surveys and Questionnaires; Time Factors; Treatment Outcome; United States; Ventricular Function, Left; Ventricular Remodeling

Background Coronary artery disease remains a major cause of death despite better outcomes of ST-segment-elevation myocardial infarction (STEMI). We aimed to analyze data from the Ruti-STEMI registry of in-hospital, 28-day, and 1-year events in patients with STEMI over the past 3 decades in Catalonia, Spain, to assess trends in STEMI prognosis. Methods and Results Between February 1989 and December 2017, a total of 7589 patients with STEMI were admitted consecutively. Patients were grouped into 5 periods: 1989 to 1994 (period 1), 1995 to 1999 (period 2), 2000 to 2004 (period 3), 2005 to 2009 (period 4), and 2010 to 2017 (period 5). We used Cox regression to compare 28-day and 1-year STEMI mortality and in-hospital complication trends across these periods. Mean patient age was 61.6±12.6 years, and 79.3% were men. The 28-day all-cause mortality declined from period 1 to period 5 (10.4% versus 6.0%;

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Female; Hospital Mortality; Humans; Long Term Adverse Effects; Male; Middle Aged; Percutaneous Coronary Intervention; Prognosis; Proportional Hazards Models; Registries; Spain; ST Elevation Myocardial Infarction; Ventricular Dysfunction, Right; Ventricular Fibrillation

More than 11 million people suffer from coronary heart disease (CHD) angina in China, showing high morbidity and mortality rates. Yufengingxin (YFNX) is a commonly used Chinese patent medicine in CHD angina treatment. The purpose of this protocol is to evaluate the effectiveness and safety of YFNX for the treatment of CHD angina.. A systematic search of randomized controlled trials related to the effectiveness and safety of YFNX in the treatment of CHD angina will be performed from relevant databases, including PubMed, Cochrane Library, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Scientific Journal Database (VIP) and Chinese Biomedical Literature Database (CBM). We will screen all the literatures from the database inception to November 1, 2020. The data including study ID, study characteristics, methodological information, patients information, interventions, comparisons and outcomes will be extracted. The frequency and duration of angina attacks will be served as the primary outcome. Review Manager 5.3 and STATA 14.0 software will be used for data analysis.. This systematic review will provide strong evidence for the effectiveness and safety of YFNX in the treatment of CHD angina.. INPLASY2020110040.

Topics: Angina Pectoris; Cardiovascular Agents; Drugs, Chinese Herbal; Humans; Isoflavones; Medicine, Chinese Traditional; Meta-Analysis as Topic; Research Design; Systematic Reviews as Topic; Treatment Outcome

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Female; Humans; Intra-Aortic Balloon Pumping; Male; Middle Aged; Percutaneous Coronary Intervention; Retrospective Studies; Risk Assessment; Risk Factors; Shock, Cardiogenic; Time Factors; Treatment Outcome

Health status and quality of life improvement after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) among patients with refractory angina has not been reported. We sought to determine the degree of quality of life improvement after CTO PCI in patients with refractory angina.. Among 1000 consecutive patients who underwent CTO PCI in a 12-center registry, refractory angina was defined as any angina (baseline Seattle Angina Questionnaire [SAQ] Angina Frequency score of ≤90) despite treatment with ≥3 antianginal medications. Health status at baseline and 1-year follow-up was quantified using the SAQ. Refractory angina was present at baseline in 148 patients (14.8%). Technical success was achieved in 120 (81.1%) at the initial attempt and major adverse cardiac and cerebral events occurred in 10 (6.8%). There were no procedural deaths. Refractory angina patients were highly symptomatic at baseline with mean SAQ Angina Frequency of 51.1±23.8, SAQ quality of life of 35.3±21.2, and SAQ Summary Score of 47.2±17.9, improving by 32.0±27.8, 35.7±23.9, and 32.1±20.1 at 1 year. Through 1-year follow-up, patients with successful CTO PCI had significantly larger degree of improvement of SAQ Angina Frequency and SAQ Summary Score (35.0±26.8 versus 18.8±28.9, P<0.01; 34.2±19.4 versus 22.5±20.8, P<0.01) compared with unsuccessful CTO PCI.. Refractory angina was present in 1 of 7 patients in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry. Patients with refractory angina experienced large, clinically significant health status improvements that persisted through 12 months, and patients with successful CTO PCI had larger health status improvement than those without.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Occlusion; Drug Resistance; Female; Health Status; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Prospective Studies; Quality of Life; Registries; Risk Factors; Time Factors; Treatment Outcome; United States

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been shown to reduce angina and improve quality of life, but the frequency of new or residual angina after CTO PCI and its relationship with titration of anti-anginal medications (AAMs) has not been described.. Among consecutive CTO PCI patients treated at 12 US centres in the OPEN CTO registry, angina was assessed 6 months after the index PCI using the Seattle Angina Questionnaire (SAQ) Angina Frequency scale (a score <100 defined new or residual angina). We then compared the proportion of patients with AAM escalation (defined as an increase in the number or dosage of AAMs between discharge and follow-up) between those with and without 6-month angina. Of 901 patients who underwent CTO PCI, 197 (21.9%) reported angina at 6-months, of whom 80 (40.6%) had de-escalation, 66 (33.5%) had no change, and only 51 (25.9%) had escalation of their AAM by the 6-month follow-up. Rates of AAM escalation were similar when stratifying patients by the ultimate success of the CTO PCI, completeness of physiologic revascularization, presence or absence of angina at baseline, history of heart failure, and by degree of symptomatic improvement after CTO PCI.. One in five patients reported angina 6 months after CTO PCI. Although patients with new or residual angina were more likely to have escalation of AAMs in follow-up compared with those without residual symptoms, only one in four patients with residual angina had escalation of AAMs. Although it is unclear whether this finding reflects maximal tolerated therapy at baseline or therapeutic inertia, these findings suggest an important potential opportunity to further improve symptom control in patients with complex stable ischaemic heart disease.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Occlusion; Female; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Postoperative Complications; Prospective Studies; Registries; Time Factors

Background Patients with chronic total occlusion ( CTO ) may not participate in regular exercise because of refractory angina. Exercise participation after percutaneous coronary intervention (PCI) for CTO ( CTO PCI ) and the association of exercise with health status after CTO PCI is unknown. Methods and Results Overall, 1000 patients enrolled in the Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion OPEN CTO is a registry were asked about participation in regular exercise at baseline and 12 months after CTO PCI , and the frequency of exercise (<1, 1-2, ≥3 times/week) was collected among exercisers. Health status was assessed using the Seattle Angina Questionnaire ( SAQ ). Multivariable regression assessed 12-month health status change across 4 groups defined by exercise frequency at baseline and 12 months after CTO PCI (no regular exercise at baseline and 12 months, reduced, increased, and consistent exercise at 12 months). Among 869 patients with complete exercise data, the proportion that exercised regularly increased from 33.5% at baseline to 56.6% 12 months after CTO PCI ( P<0.01). Predictors of regular exercise at 12 months included baseline exercise, smoking, baseline and increase in SAQ scores for angina frequency, physical limitation, quality of life, and summary. After multivariable adjustment, consistent or increased exercise frequency was associated with significantly greater improvement in SAQ scores for angina frequency, physical limitation, quality of life, and summary ( P<0.01). Conclusions Participation in regular exercise increased significantly 12 months after CTO PCI , and patients who had greater health status benefit after PCI were more likely to exercise regularly at 12 months. CTO PCI may enable coronary artery disease patients with limiting symptoms to engage in regular exercise and to support better long-term outcomes.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Occlusion; Exercise; Exercise Tolerance; Female; Follow-Up Studies; Health Status; Humans; Male; Middle Aged; Nitrates; Percutaneous Coronary Intervention; Ranolazine; Treatment Outcome

Successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can markedly reduce angina symptom burden, but many patients often remain on multiple antianginal medications (AAMs) after the procedure. It is unclear when, or if, AAMs can be de-escalated to prevent adverse effects or limit polypharmacy. We examined the association of de-escalation of AAMs after CTO PCI with long-term health status.. In a 12-center registry of consecutive CTO PCI patients, health status was assessed at 6 months after successful CTO PCI with the Seattle Angina Questionnaire and the Rose Dyspnea Scale. Among patients with technical CTO PCI success, we examined the association of AAM de-escalation with 6-month health status using multivariable models adjusting for revascularization completeness and predicted risk of post-PCI angina (using a validated risk model). We also examined predictors and variability of AAMs de-escalation.. Of 669 patients with technical success of CTO PCI, AAMs were de-escalated in 276 (35.9%) patients at 1 month. Patients with AAM de-escalation reported similar angina and dyspnea rates at 6 months compared with those whose AAMs were reduced (any angina: 22.5% vs 20%, P = .43; any dyspnea: 51.8% vs 50.1%, P = .40). In a multivariable model adjusting for complete revascularization and predicted risk of post-PCI angina, de-escalation of AAMs at 1 month was not associated with an increased risk of angina, dyspnea, or worse health status at 6 months.. Among patients with successful CTO PCI, de-escalation of AAMs occurred in about one-third of patients at 1 month and was not associated with worse long-term health status.

Topics: Aged; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Chi-Square Distribution; Chronic Disease; Coronary Occlusion; Dyspnea; Female; Health Status; Health Surveys; Humans; Logistic Models; Male; Myocardial Ischemia; Nitro Compounds; Percutaneous Coronary Intervention; Prospective Studies; Quality of Life; Ranolazine; Registries; Time Factors

Background Prior research has shown that providers may infrequently adjust antianginal medications (AAMs) following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Patient characteristics associated with AAM titration and the variation in postprocedure AAM management after CTO PCI across hospitals have not been reported. We sought to determine the frequency and potential correlates of AAM escalation and de-escalation after CTO PCI. Methods and Results Using the 12-center OPEN CTO registry (Outcomes, Patient Health Status, and Efficiency iN Chronic Total Occlusion Hybrid Procedures), we assessed AAM use at baseline and 6 months after CTO PCI. Escalation was defined as any addition of a new class of AAM or dose increase, whereas de-escalation was defined as a reduction in the number of AAMs or dose reduction. Angina was assessed 6 months after the index CTO PCI attempt using the Seattle Angina Questionnaire Angina Frequency domain. Potential correlates of AAM escalation (vs no change) or de-escalation (vs no change) were evaluated using multivariable modified Poisson regression models. Adjusted variation across sites was evaluated using median rate ratios. AAMs were escalated in 158 (17.5%), de-escalated in 351 (39.0%), and were unchanged at 6-month follow-up in 392 (43.5%). Patient characteristics associated with escalation included lung disease, ongoing angina, and periprocedural major adverse cardiac and cerebral events (periprocedural myocardial infarction, stroke, death, emergent cardiac surgery, or clinically significant perforation), whereas de-escalation was more frequent among patients taking more AAMs, those treated with complete revascularization, and after treatment of non-CTO lesions at the time of the index procedure. There was minimal variation in either escalation (median rate ratio, 1.11; P=0.36) or de-escalation (median rate ratio, 1.10; P=0.20) compared to no change of AAMs across sites. Conclusions Escalation or de-escalation of AAMs was less common than continuation following CTO PCI, with little variation across sites. Further research is needed to identify patients who may benefit from AAM titration after CTO PCI and develop strategies to adjust these medications in follow-up. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02026466.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Occlusion; Drug Administration Schedule; Female; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Prospective Studies; Registries; Time Factors; Treatment Outcome; United States

The aim of this study was to assess the safety and efficacy of the Reducer in a real-world cohort of patients presenting with refractory angina.. The coronary sinus Reducer is a novel device to aid in the management of patients with severe angina symptoms refractory to optimal medical therapy and not amenable to further revascularization.. Fifty patients with refractory angina and objective evidence of myocardial ischemia who were judged unsuitable for revascularization were treated with coronary sinus Reducer implantation at a single center between March 2015 and August 2016. Safety endpoints were procedural success and the absence of device-related adverse events. Efficacy endpoints, assessed at 4- and 12-month follow-up, were a reduction in Canadian Cardiovascular Society angina class, improvement in quality of life assessed using the Seattle Angina Questionnaire, improvement in exercise tolerance assessed using the 6-min walk test, and reduction in pharmacological antianginal therapy.. Procedural success was achieved in all patients, with no device-related adverse effects during the procedure or at follow-up. Regarding the efficacy endpoint, 40 patients (80%) had at least 1 reduction in Canadian Cardiovascular Society class, and 20 patients (40%) had at least 2 class reductions, with a mean class reduction to 1.67 ± 0.83 vs. 2.98 ± 0.52 (p < 0.001) at 4-month follow-up. All Seattle Angina Questionnaire items improved significantly (p < 0.001 for all). A significant increment in 6-min walk distance to 388.6 ± 119.7 m vs. 287.0 ± 138.9 m (p = 0.004) was observed. Sixteen patients (32%) and 3 patients (6%) demonstrated reductions of at least 1 or 2 antianginal drugs, respectively. The benefit of Reducer implantation observed at 4-month follow-up was maintained at 1 year.. In this real-world, single-center experience, implantation of the coronary sinus Reducer appeared safe and was associated with reduction in anginal symptoms and improvement in quality of life in patients with refractory angina who were not candidates for further revascularization.

Topics: Aged; Angina Pectoris; Cardiac Surgical Procedures; Cardiovascular Agents; Chronic Disease; Coronary Sinus; Equipment Design; Exercise Tolerance; Female; Humans; Italy; Male; Middle Aged; Prospective Studies; Quality of Life; Recovery of Function; Surveys and Questionnaires; Time Factors; Treatment Outcome; Walk Test

The impact of treatment strategies on outcomes in patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) according to presenting angina has not been rigorously assessed.. We performed a patient-level pooled-analysis (n = 5027) of patients with stable CAD and T2DM randomized to optimal medical therapy [OMT], percutaneous coronary intervention [PCI] + OMT, or coronary artery bypass grafting [CABG] + OMT. Endpoints were death/myocardial infarction (MI)/stroke, post-randomization revascularization (both over 5 years), and angina control at 1 year.. Increasing severity of baseline angina was associated with higher rates of death/MI/stroke (p = 0.009) and increased need for post-randomization revascularization (p = 0.001); after multivariable adjustment, only association with post-randomization revascularization remained significant. Baseline angina severity did not influence the superiority of CABG + OMT to reduce the rate of death/MI/stroke and post-randomization revascularization compared to other strategies. CABG + OMT was superior for angina control at 1 year compared to both PCI + OMT and OMT alone but only in patients with ≥ Class II severity at baseline. Comparisons between PCI + OMT and OMT were neutral except that PCI + OMT was superior to OMT for reducing the rate of post-randomization revascularization irrespective of presenting angina severity.. Presenting angina severity did not influence the superiority of CABG + OMT with respect to 5-year rates of death/MI/stroke and need for post-randomization revascularization. Presenting angina severity minimally influenced relative benefits for angina control at 1 year.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Diabetes Mellitus, Type 2; Female; Humans; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Randomized Controlled Trials as Topic; Retreatment; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke; Time Factors; Treatment Outcome

In patients with coronary artery disease (CAD), low diastolic blood pressure (DBP) is associated with increased risk of myocardial infarction, but its association with angina is unknown.. The goal of this study was to examine the association of low DBP and angina in patients with CAD.. The study assessed the frequency of angina (measured by using the Seattle Angina Questionnaire-Angina Frequency score) according to DBP in patients with known CAD from 25 U.S. cardiology clinics. Hierarchical logistic regression was used to test the association between DBP and angina, with a spline term for DBP to assess nonlinearity.. Among 1,259 outpatients with CAD, 411 (33%) reported angina in the prior month, with higher rates in the lowest DBP quartile (40 to 64 mm Hg: 37%). In the unadjusted model, DBP was associated with angina with a J-shaped relationship (p = 0.017, p for nonlinearity = 0.027), with a progressive increase in odds of angina as DBP decreased below ∼70 to 80 mm Hg. This association remained significant after sequential adjustment for demographic characteristics (p = 0.002), comorbidities (p = 0.002), heart rate (p = 0.002), systolic blood pressure (p = 0.046), and antihypertensive antianginal medications (p = 0.045).. In patients with chronic CAD, there seemed to be an association between lower DBP and increased odds of angina. If validated, these findings suggest that clinicians should consider less aggressive blood pressure control in patients with CAD and angina.

Topics: Age Factors; Aged; Angina Pectoris; Blood Pressure; Body Mass Index; Cardiovascular Agents; Coronary Artery Disease; Cross-Sectional Studies; Diastole; Diuretics; Female; Humans; Logistic Models; Male; Nitrates; Ranolazine; Renal Insufficiency, Chronic; Sex Factors; United States

Coronary artery spasm (CAS) is known to be a risk factor for cardiovascular events. However, there is limited data whether the multi-vessel and diffuse spasm (MVDS) is related to more adverse clinical outcomes compared to the Non-MVDS. The aim of this study is to evaluate the impact of the MVDS on clinical outcomes during a 3-year clinical follow-up period.A total 2797 patients underwent coronary angiography (CAG) with acetylcholine (ACH) provocation test from Nov 2004 to Oct 2010 were enrolled. It is a single-center, observational, prospective, all-comers registry designed to reflect the "real world" practic. The patients were divided into the 3 groups; the negative spasm (NS) group (n = 1188), the Non-MVDS group (n = 1081), and the MVDS group (n = 528). The incidence of major adverse cardiac events (MACE) and recurrent angina was evaluated up to 3 years. To minimize confounding factors, multivariable Cox-proportional hazards regression analysis was performed.In the 3-year clinical follow-up, the incidence of total death, myocardial infarction, de novo percutaneous coronary intervention (PCI), cerebrovascular accident and MACE were similar among the 3 groups. However, recurrent angina occurred more frequently in the MVDS group than in the NS group (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.27-3.02; P = .002). Recurrence angina between the MVDS group and the Non-MVDS group was not statistically significant (HR, 1.36; 95% CI, 0.91-2.03; P = .129).In this study, although the incidence of major adverse cardiovascular events were not different regardless of spasm type, the MVDS was associated with higher incidence of recurrent chest pain requiring repeat CAG during the 3-year follow-up period, suggesting more intensive optimal medical therapy with close clinical follow up would be necessary for this particular subset of patients.

Topics: Acetylcholine; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Vasospasm; Female; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Prognosis; Registries; Republic of Korea; Risk Factors; Time

Angina has important implications for patients' quality of life and healthcare utilization. Angina management after acute myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) is unknown.. TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) was a longitudinal study of MI patients treated with percutaneous coronary intervention at 233 US hospitals from 2010 to 2012. Among patients with self-reported angina at 6 weeks post-MI, we described patterns of angina and antianginal medication use through 1 year postdischarge. Of 10 870 percutaneous coronary intervention-treated MI patients, 3190 (29.3%) reported angina symptoms at 6 weeks post-MI; of these, 658 (20.6%) had daily/weekly angina while 2532 (79.4%) had monthly angina. Among patients with 6-week angina, 2936 (92.0%) received β-blockers during the 1 year post-MI, yet only 743 (23.3%) were treated with other antianginal medications. At 1 year, 1056 patients (33.1%) with 6-week angina reported persistent angina symptoms. Of these, only 31.2% had been prescribed non-β-blocker antianginal medications at any time in the past year. Among patients undergoing revascularization during follow-up, only 25.9% were on ≥1 non-β-blocker anti-anginal medication at the time of the procedure.. Angina is present in one third of percutaneous coronary intervention-treated MI patients as early as 6 weeks after discharge, and many of these patients have persistent angina at 1 year. Non-β-blocker antianginal medications are infrequently used in these patients, even among those with persistent angina and those undergoing revascularization.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Drug Prescriptions; Drug Utilization Review; Female; Humans; Longitudinal Studies; Male; Middle Aged; Non-ST Elevated Myocardial Infarction; Patient Discharge; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Practice Patterns, Physicians'; Prevalence; Purinergic P2Y Receptor Antagonists; Risk Factors; ST Elevation Myocardial Infarction; Time Factors; Treatment Outcome; United States

Antianginal medications (AAMs) can be perceived to be less important after percutaneous coronary intervention (PCI) and may be de-escalated after revascularization. We examined the frequency of AAM de-escalation at discharge post-PCI and its association with follow-up health status.. In a 10-center PCI registry, the Seattle Angina Questionnaire was assessed before and 6 months post-PCI. AAM de-escalation was defined as fewer AAMs at discharge versus admission or >25% absolute dose decrease. Of 2743 PCI patients (70% male), AAM were de-escalated, escalated, and unchanged in 299 (11%), 714 (26%), and 1730 (63%) patients, respectively. Patients whose AAM were de-escalated were more likely to report angina at 6 months, compared with unchanged or escalated AAM (34% versus 24% versus 21%;. De-escalation of AAM occurs in 1 in 10 patients post-PCI, and it is associated with an increased risk of angina and worse health status, particularly among those with incomplete revascularization.

Topics: Aged; Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Coronary Artery Disease; Drug Administration Schedule; Female; Health Status; Humans; Male; Middle Aged; Non-ST Elevated Myocardial Infarction; Patient Discharge; Percutaneous Coronary Intervention; Prospective Studies; Quality of Life; Registries; Risk Factors; Surveys and Questionnaires; Time Factors; Treatment Outcome; United States

Calcium channel blockers diltiazem and nitrate have been used as selective coronary vasodilators for patients with significant coronary artery spasm (CAS). However, no study has compared the efficacy of diltiazem alone versus diltiazem with nitrate for long-term clinical outcomes in patients with CAS.. A total of 2741 consecutive patients without significant coronary artery disease with positive CAS by acetylcholine (Ach) provocation test between November 2004 and May 2014 were enrolled. Significant CAS was defined as a narrowing of >70% by incremental intracoronary injection of 20, 50, and 100 μg of Ach into the left coronary artery. Patients were assigned to either the diltiazem group (n=842) or the dual group (diltiazem with nitrate, n=1899) at physician discretion. To adjust for potential confounders, a propensity score matching (PSM) analysis was performed using the logistic regression model. After PSM analysis, two well-balanced groups (811 pairs, n=1622, C-statistic=0.708) were generated.. At 5 years, there were similar incidences in primary endpoints, including mortality, myocardial infarction, revascularization, and recurrent angina requiring repeat coronary angiography between the two groups. Diltiazem alone was not an independent predictor for major adverse cardiovascular events or recurrent angina requiring repeat coronary angiography.. Despite the expected improvement of endothelial function and the relief of CAS, the combination of diltiazem and nitrate treatment was not superior to diltiazem alone in reducing mortality and cardiovascular events up to 5 years in patients with significant CAS.

Topics: Acetylcholine; Aged; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Vasospasm; Diltiazem; Drug Therapy, Combination; Female; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Nitrates; Propensity Score; Time Factors; Vasodilator Agents

Topics: Adult; Allografts; Angina Pectoris; Cardiovascular Agents; Drug Therapy, Combination; Heart Transplantation; Humans; Male; Ranolazine; Vascular Diseases

Angina pectoris (AP) is common in coronary artery disease (CAD), but whether those with diabetes mellitus (DM) experience AP as often as those without DM is unclear.. AP prevalence is similar in those with vs without DM in a community sample with CAD.. In adults with CAD in the US NHANES 2001-2010, AP was determined by self-report and Rose questionnaire and compared by DM status. Physical functioning and medication use were also evaluated.. Of 1957 adults with CAD, 619 (28.2%) had DM. Prevalence of AP was similar in those with vs without DM (48.9% vs 46.3%; P = 0.38). There was a trend toward more severe AP in those with glycated hemoglobin ≥7% (50.4%) vs <7% (27.1%; P = 0.09). Adjusted logistic regression showed a similar odds of AP (1.06, 95% CI: 0.84-1.33) in those with vs without DM, although among DM, a 2-fold greater odds of AP in women vs men. Physical functioning was worse in those with vs without AP overall (score of 25.9 vs 24.3; P < 0.001) and further diminished within those with comorbid DM (26.7 vs 24.0; P < 0.001). Among those with AP, those with vs without DM were more likely on β-blockers, statins, angiotensin-converting enzyme inhibitors, and antiplatelet therapy.. AP in CAD patients is similar among those with vs without DM, despite greater use of evidence-based therapies in DM patients. Greater physical limitations exist in those with vs without AP, and further diminish with comorbid DM.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Chi-Square Distribution; Comorbidity; Coronary Artery Disease; Cross-Sectional Studies; Diabetes Mellitus; Exercise Tolerance; Female; Health Status; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Logistic Models; Male; Middle Aged; Nutrition Surveys; Odds Ratio; Prevalence; Risk Factors; Self Report; United States

This survey study was performed to provide an overall picture on the incidence of symptoms, with or without typical angina, in the real-life clinical practice and to identify clinical factors associated with atypical presentations in an unselected population of consecutive outpatients with chronic coronary artery disease (CAD).. Thirty-six cardiology units located in different geographic areas of Italy enrolled a total of 1475 outpatients (73.6% men and 26.3% women; mean age 71 ± 10 and 67 ± 9 years in men and women, respectively) with a documented diagnosis of chronic CAD. Each patient underwent a medical history, with a detailed investigation as to the presence of typical angina or ischemic equivalents defined as sensation of chest pressure, or arm, neck, or jaw pain.. At admission, symptoms suggesting ischemic episodes were reported by 24.4% of patients. After an in-depth medical history collection by the specialist, the prevalence of combined typical or atypical myocardial ischemic episodes was ascertained in 39.3% of the overall population.Typical angina was reported by 13.6% of men and 22.7% of women (P < 0.0001), whereas ischemic equivalents were present in 7.3 and 12.9% of male and female patients, respectively (P < 0.001). Previous coronary artery bypass grafting (CABG; P < 0.001) and fewer medical visits by cardiologists (P = 0.02) were independent predictors of atypical presentations.. The ISPICA study shows that in an Italian population of real-world patients with chronic CAD, ischemic episodes, with both typical and atypical presentation, are still present in nearly 50% of patients, despite optimal medical therapy, and that atypical presentations of angina are linked to fewer visits by specialists and previous CABG. These findings would suggest to encourage patients with chronic CAD and general practitioners to consider more frequent cardiology specialist visits and to take into account the possibility of atypical presentations, particularly in patients with previous CABG.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Female; Health Surveys; Humans; Incidence; Italy; Male; Middle Aged; Myocardial Ischemia; Myocardial Revascularization; Risk Factors

Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries.. Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015.. We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes.. Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.

Topics: Adult; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Educational Status; Electrocardiography; Emergency Medical Services; Emergency Service, Hospital; Emigrants and Immigrants; Female; Hospital Mortality; Humans; Male; Middle Aged; Middle East; Myocardial Infarction; Percutaneous Coronary Intervention; Prospective Studies; Registries; Socioeconomic Factors; Time Factors; Treatment Outcome; Triage

Refractory angina pectoris (RAP) represents a clinical condition characterized by frequent episodes of chest pain despite therapy optimization. According to myocardial stunning and myocardial hibernation definitions, RAP should represent the ideal condition for systolic dysfunction development. We aim to investigate the evolution of left ventricular (LV) function in patients with RAP. A retrospective study which encompasses 144 patients with RAP referred to our institution from 1999 to December 2014 was performed. Of them, 88 met the inclusion criteria, and LV function was assessed by echocardiography. All of them had persistent angina episodes on top of optimal medical therapy and evidence of significant inducible myocardial ischemia and no further revascularization options. Nitrates consumption rate, time of angina duration, and the number of angina attacks were evaluated. In the whole population, ejection fraction (EF) was 44% ± 2. EF was significantly lower in patients with previous myocardial infarction (41% ± 1.5 vs 51% ± 1.8, p <0.0001). The duration time and the number of angina attacks did not correlate with EF in the whole population and in patients without previous myocardial infarction. In patients with previous myocardial infarction, the number of anginal attacks did not correlate with EF, but EF appeared higher in patients with angina duration >5 years (<5 years EF 37% ± 1 [n = 26]; >5 years 44% ± 2 [n = 44]; p 0.02). Long-term LV function in patients with RAP is generally preserved. A previous history of myocardial infarction is the only determinant in the development of systolic dysfunction. In conclusion, frequent angina attacks and a long-term history of angina are not apparently associated to worse LV function.

Topics: Aged; Angina Pectoris; Benzazepines; Cardiovascular Agents; Echocardiography; Exercise Test; Female; Follow-Up Studies; Humans; Ivabradine; Male; Myocardial Ischemia; Ranolazine; Retrospective Studies; Sodium Channel Blockers; Stroke Volume; Systole; Time Factors; Tomography, Emission-Computed, Single-Photon; Trimetazidine; Vasodilator Agents; Ventricular Function, Left

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Benzazepines; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Drug Combinations; Humans; Ivabradine; Metoprolol; Recurrence

Topics: Angina Pectoris; Benzazepines; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Dose-Response Relationship, Drug; Drug Combinations; Humans; Ivabradine; Metoprolol; Physical Fitness

Topics: Angina Pectoris; Cardiovascular Agents; Humans

Topics: Aged; Angina Pectoris; Cardiomyopathy, Hypertrophic; Cardiovascular Agents; Dyspnea; Female; Humans; Male; Middle Aged; Pilot Projects; Ranolazine

Almost a third of outpatients with chronic coronary artery disease (CAD) report having angina in the prior month, which is frequently under-recognized by their cardiologists. Whether under-recognition is associated with less treatment escalation to control angina, and potential underuse of treatment, is unknown.. Patients with CAD from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire (SAQ) prior to their clinic visit, and angina was categorized as daily, weekly, monthly and no angina. Cardiologists (n=155) independently quantified patients' angina, blinded to patients' SAQ scores. Under-recognition was defined as the physician reporting a lower category of angina frequency than the patient. Among 1257 patients with CAD, 411 reported angina in the past month, of whom 178 (43.3%) patients were under-recognized. Treatment escalation-defined as intensification (up-titration or addition) of antianginal medications, referral for diagnostic testing or revascularization, or hospital admission-occurred in 106 (25.8%) patients with angina. Patients with under-recognized angina were less likely to get treatment escalation than patients whose angina was appropriately recognized (8.4% vs 39.1%, P<0.001). In a hierarchical multivariable logistic regression model adjusting for demographic and clinical characteristics, as well as the burden of angina, under-recognition remained strongly associated with a lack of treatment escalation (adjusted OR 0.10, 95% CI 0.04-0.21, P<0.001).. Under-recognition of angina in cardiology outpatient practices is associated with less aggressive treatment escalation and may lead to poorer angina control. Standardizing clinical recognition of angina using validated tools could reduce under-recognition of angina, facilitate treatment, and potentially improve outcomes.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiologists; Cardiovascular Agents; Clinical Competence; Coronary Artery Disease; Cross-Sectional Studies; Female; Health Status; Humans; Male; Middle Aged; Myocardial Ischemia; Outpatients; Practice Patterns, Physicians'; Prevalence; Quality Indicators, Health Care; United States

to analyze causes of attacks of angina pectoris and assess impact of optimization of antianginal therapy on frequency of attacks provoked by various factors.. We analyzed diaries of 1226 survivors of myocardial infarction (MI) which occurred within 12months before inclusion in the LINKOR program. Causes of pain and their changes with correction of antianginal therapy were registered during 16 weeks of follow-up.. Participants of the study indicated the following factors as causes of pain: physical exertion (74.9%), psycho-emotional stress (52.6%), meteorological factors (25.9%), elevation of arterial pressure(AP) (18.8%), meals (12.1%), alcohol intake (4.7%), sexual activity (4.4%). Attacks at rest in wakeful state and during sleep were reported by 4.5 and 4.5% of patients, respectively. Prescription of ivabradine and in some cases correction of antihypertensive therapy led to double reduction of the number of patients who indicated physical exertion as a cause of angina. Numbers of patients with attacks caused by meals, AP elevation, psycho-emotional stress, alcohol intake, unfavorable meteorological conditions, and sexual activity decreased by 83.2, 75, 63.3, 63.6, 61.3, and 60.9%, respectively. Numbers of patients with attacks at rest in wakeful state, and at night decreased by 79.8 and 69%, respectively. More than two thirds of patients achieved class I of angina.. Optimization of antianginal therapy directed to lowering or myocardial oxygen consumption leads to reduction of frequency of attacks of pain caused by various triggers. This improves quality of life, increases everyday activity, secures independence, and loweres risk of depression and anxiety.

Topics: Aged; Angina Pectoris; Benzazepines; Cardiovascular Agents; Female; Humans; Ivabradine; Male; Middle Aged; Myocardial Infarction; Physical Exertion; Quality of Life; Risk Factors

While patients with diabetes mellitus (DM) have more extensive coronary disease and worse survival after acute myocardial infarction (AMI) than patients without DM, data on whether they experience more angina are conflicting.. We examined angina prevalence over the year following AMI among 3367 patients, including 1080 (32%) with DM, from 24 US hospitals enrolled in the TRIUMPH registry from 2005 to 2008.. Patients with vs. without DM were more likely to be treated with antianginal medications both at discharge and over follow up. Despite more aggressive angina therapy, patients with vs. without DM had higher prevalence and severity of angina prior to AMI (49 vs. 43%, p = 0.001) and at each follow-up assessment, although rates of angina declined in both groups over time. In a hierarchical, multivariable, repeated-measures model that adjusted for multiple demographic and clinical factors including severity of coronary disease and in-hospital revascularization, DM was associated with a greater odds of angina over the 12 months of follow up; this association increased in magnitude over time (12-month OR 1.18, 95% CI 1.01-1.37; DM*time pinteraction = 0.008).. Contrary to conventional wisdom, angina is more prevalent and more severe among patients with DM, both prior to and following AMI. This effect is amplified over time and independent of patient and treatment factors, including the presence of multivessel disease and coronary revascularization. This increased burden of angina may be due to more diffuse nature of coronary disease, more rapid progression of coronary disease over time, or greater myocardial demand among DM patients.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Diabetes Mellitus; Female; Health Status; Humans; Hypoglycemic Agents; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Odds Ratio; Prevalence; Prognosis; Prospective Studies; Registries; Risk Factors; Severity of Illness Index; Surveys and Questionnaires; Time Factors; United States

Coronary endothelial dysfunction is thought to underlie the development of coronary artery spasms. Malondialdehyde-modified low-density lipoprotein (MDA-LDL) was suggested as a marker of endothelial damage. This study investigated the diagnostic impact of MDA-LDL on ergonovine-induced coronary spasms.. We included 152 patients with suspected coronary spastic angina. MDA-LDL levels were measured before an ergonovine provocation test. Coronary spasm was defined as total or subtotal occlusion, compared to the relaxed state after nitroglycerin, associated with ischemic ECG changes and concurrent chest pain. Changes in vessel diameter in response to ergonovine were evaluated with quantitative coronary angiography.. Coronary spasms were observed in 41 patients (27%). MDA-LDL levels were significantly higher in patients with spasms compared to those without spasms (139.9 ± 45.9 U/L vs. 109.6 ± 36.6 U/L, p<0.01). Univariate logistic regression analyses indicated significant relationships between coronary spasms and MDA-LDL (per 10 U/L, odds ratio (OR): 1.20; p<0.01), high-density lipoprotein (per 10 mg/dL, OR: 0.76; p=0.03), smoking (OR: 3.04; p<0.01), and male gender (OR: 3.51; p<0.01). In the multivariate model, MDA-LDL (per 10 U/L, OR: 1.17; p<0.01) remained a significant predictor of coronary spasm. Regression analysis showed a positive correlation between MDA-LDL levels and coronary luminal diameter changes induced by ergonovine (r=0.57, p<0.01). The optimal MDA-LDL threshold for predicting coronary spasm was 121.3 U/L, identified with a receiver operating characteristic curve.. Increased circulating MDA-LDL levels were associated with ergonovine-induced coronary artery spasm.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Vasospasm; Coronary Vessels; Endothelium, Vascular; Ergonovine; Female; Humans; Lipoproteins, LDL; Male; Malondialdehyde; Middle Aged; Nitroglycerin; Statistics as Topic

This paper put forward a deconvolution-based method for designing and optimizing tanshinone IIA sustained-release pellets (TA-SRPs) with improved efficacy in the treatment of variant angina. TA-SRPs were prepared by coating TA ternary solid dispersion immediate-release pellets (TA-tSD-IRPs) with the blends of polyvinyl acetate (PVAc) and polyvinyl alcohol-polyethylene glycol (PVA-PEG) using fluidized bed technology. The plasma concentration-time curve of TA-tSD-IRPs following oral administration as a weight function was investigated in New Zealand white rabbits. The predicted/expected plasma concentration-time curve of TA-SRPs as a response function was simulated according to the circadian rhythm of variant angina during 24h based on chronotherapy theory. The desired drug release profile of TA-SRPs was obtained via the point-area deconvolution procedure using the weight function and response function, and used for formulation optimization of TA-SRPs. The coating formulation of TA-SRPs was optimized as 70:30 (w/w) PVAc/PVA-PEG with 5% (w/w) coating weight due to in vitro drug release profile of these TA-SRPs was similar to the desired release profile (similarity factor f2=64.90). Pharmacokinetic studies of these optimized TA-SRPs validated that their actual plasma concentration-time curve possessed a basically consistent trend with the predicted plasma concentration-time curve and the absolute percent errors (%PE) of concentrations in 8-12h were less than 10%. Pharmacodynamic studies further demonstrated that these TA-SRPs had stable and improved efficacy with almost simultaneous drug concentration-efficacy. In conclusion, deconvolution could be employed in the development of TA-SRPs for angina chronotherapy with simultaneous drug efficacy and reduced design blindness and complexity.

Topics: Abietanes; Administration, Oral; Angina Pectoris; Animals; Cardiovascular Agents; Chemistry, Pharmaceutical; Computer Simulation; Delayed-Action Preparations; Disease Models, Animal; Drug Chronotherapy; Excipients; Male; Models, Biological; Nitric Oxide; Polyethylene Glycols; Polyvinyl Alcohol; Polyvinyls; Rabbits; Solubility; Technology, Pharmaceutical

Previous literature from high-income countries has repeatedly shown sex differences in the presentation, diagnosis, and management of acute coronary syndromes (ACS), with women having atypical presentations and undergoing less aggressive diagnostic and therapeutic measures. However, much less data exist evaluating sex differences in ACS in India.. This study sought to evaluate sex differences in the diagnosis, management, and treatment of patients with ACS in Kerala, India.. The Kerala ACS Registry collected data from 25,748 consecutive ACS admissions (19,923 men and 5,825 women) from 125 hospitals in the Indian state of Kerala from 2007 to 2009. This study evaluated the association between sex differences in presentation, in-hospital management, and discharge care with in-hospital mortality and in-hospital major adverse cardiovascular events (defined as death, reinfarction, stroke, heart failure, or cardiogenic shock).. Women with ACS were older than men with ACS (64 vs. 59, p < 0.001) and were more likely to have a history of previous myocardial infarction (16% vs. 14%, p < 0.001). Inpatient diagnostics and management and discharge care were similar between sexes. No significant differences between men and women in the outcome of death (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.80 to 1.38) or in the composite outcome of death, reinfarction, stroke, heart failure, or cardiogenic shock (OR: 0.99, 95% CI: 0.79 to 1.25) were seen after adjustment for possible confounding factors.. In Kerala, even though women with ACS were older and more likely to have previous myocardial infarction, there were no significant differences in in-hospital and discharge management, in-hospital mortality, or major adverse cardiovascular events between sexes. Whether these results apply to other parts of India or acute presentations of other chronic diseases in low- and middle-income countries warrants further study.

Topics: Acute Coronary Syndrome; Angina Pectoris; Cardiovascular Agents; Female; Hospital Mortality; Hospitalization; Humans; India; Male; Middle Aged; Registries; Sex Distribution

Since 2009, the United Kingdom diving incident data show an increasing number of fatalities in the over-50s age group. Previous studies also suggest some divers take cardiac medications. Since 2001, diving medicals have not been mandatory for UK sport divers. Instead, an annual medical self-certification form, submitted to their club/school or training establishment, is required. We documented in a survey of UK sport divers the prevalence of cardiac events and medications and the frequency of medical certifications.. An anonymous on-line questionnaire was publicised. Measures included diver and diving demographics, prescribed medications, diagnosed hypertension, cardiac issues, events and procedures, other health issues, year of last diving medical, diagnosed persistent foramen ovale (PFO), smoking and alcohol habits, exercise and body mass index.. Of 672 completed surveys, hypertension was reported by 119 (18%) with 25 of these (21%) having not had a diving medical. Myocardial infarction 6 (1%), coronary artery bypass grafting 3 (< 1%), atrial fibrillation 19 (3%) and angina 12 (2%) were also reported. PFOs were reported by 28 (4%), with 20 of these opting for a closure procedure. From 83 treated incidences of decompression illness (DCI), 19 divers reported that a PFO was diagnosed.. Divers inevitably develop health problems. Some continue to dive with cardiac issues, failing to seek specialised diving advice or fully understand the role of the diving medical. Physicians without appropriate training in diving medicine may inform a diver they are safe to continue diving with their condition without appreciating the potential risks. The current procedure for medical screening for fitness to dive may not be adequate for all divers.

Topics: Adolescent; Adult; Age Distribution; Aged; Alcohol Drinking; Angina Pectoris; Atrial Fibrillation; Body Mass Index; Cardiovascular Agents; Cardiovascular Diseases; Certification; Coronary Artery Bypass; Decompression Sickness; Diving; Exercise; Female; Foramen Ovale, Patent; Health Status; Humans; Hypertension; Male; Middle Aged; Myocardial Infarction; Recreation; Smoking; Surveys and Questionnaires; Time Factors; United Kingdom

To conduct an economic evaluation comparing ranolazine as add-on therapy to standard-of-care (SoC) with SoC alone in patients with stable angina who did not respond adequately to first line therapy, in Greece.. A decision tree model was locally adapted in the Greek setting to evaluate the cost-utility of ranolazine during a 6-month period. The analysis was conducted from a third-party payer perspective. The clinical inputs were extracted from the published literature. The cost inputs considered in the model reflect drug acquisition, hospitalizations, vascular interventions and monitoring of patients. The resource utilization data were obtained from 3 local experts. All costs refer to the year 2014. Cost-effectiveness was assessed by means of the incremental cost per quality adjusted life year (QALY) gained with the ranolazine as add-on therapy relative to SoC alone (ICER). Probabilistic sensitivity analysis (PSA) was performed.. Ranolazine as add-on therapy was more costly compared to SoC alone, as the 6-month total cost per patient was €1170 and € 984, respectively. Patients received ranolazine plus SoC and SoC alone gained 0.3155 QALYs and 0.2752 QALYs, respectively. Ranolazine plus SoC resulted in an ICER equal to €4620 per QALY gained, well below the threshold of €34,000 per QALY gained. The PSA showed that the likelihood of ranolazine plus SoC being cost-effective at the threshold of €34,000 per QALY gained was 100 %.. Τhe results suggest that ranolazine as add-on treatment may be a cost-effective alternative for the symptomatic treatment of patients with chronic stable angina in Greece.

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Cost-Benefit Analysis; Decision Trees; Dose-Response Relationship, Drug; Greece; Humans; Middle Aged; Quality of Life; Quality-Adjusted Life Years; Ranolazine; Standard of Care

We sought to evaluate the prognosis of different treatment strategies on patients with multivessel coronary disease and high SYNTAX score. 171 patients with multivessel coronary disease and SYNTAX score ε33, who underwent coronary angiography between July 2009 and July 2010 at our hospital were retrospectively selected and divided into incomplete and complete revascularization intervention groups (IR), a coronary artery bypass surgery group (CABG), a conservative drug therapy group according to treatment strategies chosen and agreed by the patients. These patients were followed up for 19.44 ± 5.73 months by telephone or outpatient service. We found the medical treatment group has a lower overall survival than the IR, CR group, and CABG group (P log-rank values are 0.03, 0.03, and 0.02, respectively). The medical treatment group also has a lower survival than the IR group, CR group, and CABG group in cerebral stroke and recurrent myocardial infarction (MI) (P log-rank values are 0.004, 0.03, and 0.001, respectively) and MACE events (P log-rank values are 0.003, 0.001 and P < 0.001, respectively). The medical treatment group and IR group have lower survival in recurrent angina pectoris than the CR group and CABG group (P log-rank values are 0.02, 0.02 and 0.03, 0.008, respectively). There are no significant differences between the CR group and the CABG group in number of deaths, strokes and recurrent MIs, MACE events, angina pectoris (P log-rank values are 0.69, 0.53, and 0.86, respectively). The IR group shows a lower survival than the CR group and CABG group only in angina pectoris (P log-rank values are 0.03 and 0.008, respectively). For the patients with a high SYNTAX score, medical treatment is still inferior to revascularization therapy (interventional therapy or coronary artery bypass surgery). It appears that the CABG is not obviously superior to the coronary intervention therapy. Complete revascularization and coronary artery bypass grafting treatments simply have better survival in angina pectoris compared to the incomplete revascularization. Therefore, individual treatment strategies are recommended and more trials are required to study these effects.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Stroke; Survival Analysis

Topics: Angina Pectoris; Atherosclerosis; Blood Specimen Collection; Cardiovascular Agents; Coronary Angiography; Edetic Acid; Humans; Mean Platelet Volume; Metabolic Syndrome; Thromboxane A2

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Comorbidity; Coronary Angiography; Coronary Circulation; Coronary Disease; Diagnostic Imaging; Diagnostic Techniques, Cardiovascular; Disease Management; European Union; Female; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Physical Exertion; Practice Guidelines as Topic; Prognosis; Risk Factors; Unnecessary Procedures

Topics: Angina Pectoris; Atrial Fibrillation; Benzazepines; Cardiovascular Agents; Heart Failure; Heart Rate; Humans; Ivabradine; Medication Therapy Management; Middle Aged; Randomized Controlled Trials as Topic; Risk Assessment

An 82-year old woman presented with chest pain and was diagnosed as having acute myocardial infarction. Coronary angiography (CAG) showed 90% stenosis in the proximal left anterior descending artery (LAD). The patient underwent percutaneous coronary intervention using a sirolimus-eluting stent (SES). A repeat CAG performed 6 months after SES implantation revealed no problems. Eight years later, the patient presented with recurrent angina. CAG showed severe stenosis of the SES with a large aneurysm. We performed off-pump coronary artery bypass grafting without ligation or plication of the LAD, but with the application of fibrin glue to the coronary artery aneurysm. The postoperative course was uneventful. The mechanism responsible for the occurrence of coronary artery aneurysms occurring late after drug-eluting stent implantation remains unclear, and the treatment strategy remains controversial. Herein, we discuss a surgical treatment for this rare entity.

Topics: Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Coronary Aneurysm; Coronary Angiography; Coronary Artery Bypass, Off-Pump; Drug-Eluting Stents; Female; Fibrin Tissue Adhesive; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; Prosthesis Design; Sirolimus; Time Factors; Tomography, X-Ray Computed; Treatment Outcome

The aim of the study was to evaluate results of combined therapy of stable 2-3 FC angina of effort with metabolic syndrome including metformin. Group 1 was comprised of 71 patients (38 (53.3%) men and 33 (46.5%) women), group 2 consisted of 57 patients treated with isosorbid-5 mononitrate (40 mg/d + amlodipin (5 mg/d) + eprosartan (600 mg/d) + thrombo ASS (100 mg/d) + carvedilol (25 mg/d) + atorvastatin (20 mg/d). Effects of the treatment were assessed 3, 6, and 12 months after its onset. At the end of the study, fasting blood glucose, total cholesterol, triglyceride, and low density lipoproteide levels decreased by 12.8, 10.9, 12.9 and 13.6% respectively compared with the initial values (p < 0.01). The level of high density lipoproteides increased by 10.4% (p < 0.01). Supplementation of therapy with metformin (1000 mg) decreased the frequency of episodes of painful and painless myocardial ischemia by 17.0 and 21.1%. Simultaneously, tolerance of physical load increased by 22.7%.

Topics: Adult; Aged; Angina Pectoris; Anticholesteremic Agents; Cardiovascular Agents; Drug Therapy, Combination; Female; Humans; Male; Metabolic Syndrome; Metformin; Middle Aged; Treatment Outcome

Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina.. This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina.. Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Topics: Adrenergic beta-Antagonists; Age Factors; Aged; Angina Pectoris; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Coronary Disease; Cross-Sectional Studies; Delivery of Health Care; Female; Health Care Surveys; Healthcare Disparities; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Outcome and Process Assessment, Health Care; Platelet Aggregation Inhibitors; Practice Patterns, Physicians'; Primary Health Care; Secondary Care; Secondary Prevention; Sex Factors; Socioeconomic Factors; State Medicine; Treatment Outcome; United Kingdom

This study aimed to develop and evaluate a novel multi-unit tablet that combined a pellet with a sustained-release coating and a tablet with a pulsatile coating for the treatment of circadian rhythm diseases. The model drug, isosorbide-5-mononitrate, was sprayed on microcrystalline cellulose (MCC)-based pellets and coated with Eudragit(®) NE30D, which served as a sustained-release layer. The coated pellets were compressed with cushion agents (a mixture of MCC PH-200/ MCC KG-802/PC-10 at a ratio of 40:40:20) at a ratio of 4:6 using a single-punch tablet machine. An isolation layer of OpadryII, swellable layer of HPMC E5, and rupturable layer of Surelease(®) were applied using a conventional pan-coating process. Central-composite design-response surface methodology was used to investigate the influence of these coatings on the square of the difference between release times over a 4 h time period. Drug release studies were carried out on formulated pellets and tablets to investigate the release behaviors, and scanning electron microscopy (SEM) was used to monitor the pellets and tablets and their cross-sectional morphology. The experimental results indicated that this system had a pulsatile dissolution profile that included a lag period of 4 h and a sustained-release time of 4 h. Compared to currently marketed preparations, this tablet may provide better treatment options for circadian rhythm diseases.

Topics: Administration, Oral; Angina Pectoris; Cardiovascular Agents; Cellulose; Chemistry, Pharmaceutical; Chronobiology Disorders; Delayed-Action Preparations; Drug Carriers; Excipients; Hypromellose Derivatives; Isosorbide Dinitrate; Kinetics; Methacrylates; Methylcellulose; Microscopy, Electron, Scanning; Polymers; Solubility; Tablets; Technology, Pharmaceutical

Topics: Angina Pectoris; Blood Flow Velocity; Cardiovascular Agents; Combined Modality Therapy; Coronary Circulation; Coronary Restenosis; Coronary Stenosis; Hemodynamics; Humans; Multicenter Studies as Topic; Myocardial Infarction; Patient Selection; Percutaneous Coronary Intervention; Randomized Controlled Trials as Topic; Severity of Illness Index; Treatment Outcome

The aim of this study was to compare acute hospital utilization and costs for patients with refractory angina pectoris undergoing spinal cord stimulation (SCS) versus enhanced external counterpulsation (EECP).. Seventy-three persons were included in this register study. The acute hospital utilization and costs for SCS and EECP were followed over a period from 12 months before treatment to 24 months after treatment using Patient Administrative Support in Skåne for publicly organized care.. SCS was significantly more expensive than EECP (P < 0.001). Both SCS and EECP entailed fewer days of hospitalization for coronary artery disease in the 12-month follow-up compared with the 12 months preceding treatment. Patients treated with EECP showed an association between reduced hospital admissions and an improved Canadian Cardiovascular Society classification class compared with 1 year before treatment. A significant reduction in cost was seen in both the SCS group (P = 0.018 and P = 0.001, respectively) and the EECP group (P = 0.002 and P = 0.045, respectively) during 12 and 24 months of follow-up compared with before treatment. There were no significant differences between the groups for hospitalization days or admissions, including costs, at the different follow-ups.. Cost-effective treatment modalities such as SCS and EECP are valuable additions to medical and revascularization therapy in patients with refractory angina pectoris. Pre-existing conditions and the patient's preferences should be taken in consideration when clinicians choose between treatments for this group of patients.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Counterpulsation; Female; Hospital Charges; Hospitals; Humans; Length of Stay; Male; Middle Aged; Spinal Cord Stimulation

Topics: Angina Pectoris; Cardiovascular Agents; Humans

Severe inoperable aortic stenosis is a challenge for clinicians. Management of symptoms with traditional antianginal agents, which exert hemodynamic changes often may not be possible in such patient groups. We report the first known case of the safe use of ranolazine with good symptomatic relief of angina in an 88-year-old lady with isolated severe aortic stenosis (without significant coronary disease) who was not suitable for surgical or percutaneous valve replacement due to medical comorbidity.

Topics: Acetanilides; Aged, 80 and over; Angina Pectoris; Aortic Valve Stenosis; Cardiovascular Agents; Female; Humans; Mitral Valve Stenosis; Piperazines; Ranolazine; Severity of Illness Index; Treatment Outcome

Although spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, it should be considered during the evaluation of patients who have chest pain. Coronary vasospasm can lead to spontaneous dissection. The dopamine agonist cabergoline is known to cause digital vasospasm. Herein, we report a case of spontaneous right coronary artery dissection in a 43-year-old woman who was taking cabergoline as therapy for prolactinoma. To our knowledge, this is the first report of an apparent relationship between cabergoline therapy and spontaneous coronary artery dissection. The possible association of cabergoline with coronary artery spasm and dissection should be considered in patients who present with chest pain while taking this medication.

Topics: Adult; Angina Pectoris; Antineoplastic Agents, Hormonal; Aortic Dissection; Cabergoline; Cardiovascular Agents; Coronary Aneurysm; Coronary Angiography; Coronary Vasospasm; Ergolines; Female; Humans; Pituitary Neoplasms; Predictive Value of Tests; Prolactinoma; Recurrence; Risk Factors; Time Factors; Treatment Outcome

The purpose of the study was to analyze the causes of postoperative myocardial infarction (PMI) and the impact of different treatment strategies on (1) postoperative outcome, (2) major adverse events (MACE), and (3) postoperative Canadian Cardiovascular Society (CCS) at 3-year follow-up.. Between May 2001 and July 2006, 113 patients with PMI were categorized in three groups: (A) conservative therapy (50 patients); (B) percutaneous coronary intervention (PCI) (25 patients), and (C) re-CABG (38 patients).. Overall in-hospital mortality was 7.1% (n = 8), being 10.0% in group A (n = 5), 4.0% in group B (n = 1) and 5.3% (n = 2) in group C (p = n.s.), respectively. The cumulative survival rates at 3 years were 90% for group A, 92% for group B, and 89.5% for group C (p = n.s). The MACE rate at 3-year follow-up for all patients was 27.4% and was significantly higher in group A (34%) and group B (36%) compared with group C (13.2%) (p = 0.05). Mean CCS was significantly reduced at follow-up in the groups compared with the preoperative angina class. However, group B and C showed a significant improvement in CCS compared with group A (p = 0.044/p < 0.001). Further group C was superior to group B (p = 0.032).. At 3 years of follow-up, this study showed no survival benefits from any therapeutical procedure; however patients treated with re-CABG had better freedom from repeat revascularization procedures and from MACCE. In addition, the conservative and PCI group had a higher incidence of recurrence of angina.

Topics: Aged; Angina Pectoris; Biomarkers; Cardiovascular Agents; Chi-Square Distribution; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Electrocardiography; Female; Hospital Mortality; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Perioperative Period; Recurrence; Reoperation; Retrospective Studies; Risk Factors; Survival Rate; Time Factors; Treatment Outcome

The Second Medicine, Angioplasty, or Surgery Study (MASS II) included patients with multivessel coronary artery disease and normal systolic ventricular function. Patients underwent coronary artery bypass graft surgery (CABG, n=203), percutaneous coronary intervention (PCI, n=205), or medical treatment alone (MT, n=203). This investigation compares the economic outcome at 5-year follow-up of the 3 therapeutic strategies.. We analyzed cumulative costs during a 5-year follow-up period. To analyze the cost-effectiveness, adjustment was made on the cumulative costs for average event-free time and angina-free proportion. Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years and 2.07 quality-adjusted life-years; PCI presented 3.59 and 2.77 quality-adjusted life-years; and CABG demonstrated 4.4 and 2.81 quality-adjusted life-years. The event-free costs were $9071.00 for MT; $19,967.00 for PCI; and $18,263.00 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P<0.01) and versus CABG (P<0.01) and CABG versus PCI (P=0.01). The event-free plus angina-free costs were $16,553.00, $25,831.00, and $24,614.00, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P=0.04), and versus CABG (P<0.001); there was no difference between CABG and PCI (P>0.05).. In the long-term economic analysis, for the prevention of a composite primary end point, MT was more cost effective than CABG, and CABG was more cost-effective than PCI.. www.controlled-trials.com.. ISRCTN66068876.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Cost-Benefit Analysis; Diagnostic Techniques, Cardiovascular; Disease-Free Survival; Female; Follow-Up Studies; Health Resources; Hospitalization; Humans; Male; Middle Aged; Multicenter Studies as Topic; Office Visits; Postoperative Complications; Prospective Studies; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Treatment Outcome

The Impact of Nicorandil in Angina (IONA) trial demonstrated that the use of nicorandil, an anti-anginal drug, reduced future cardiovascular events in patients with stable angina. We hypothesized that nicorandil has beneficial effects on coronary arterial plaque characteristics and atherosclerogenesis.. Preintervention intravascular ultrasound-virtual histology was performed prospectively in 65 consecutive patients with stable angina pectoris. There were no differences in coronary risk factors between the nicorandil (n = 16) and non-nicorandil (n = 49) groups. However, the nicorandil group demonstrated a larger %fibrous tissue (68 ± 10 vs. 62 ± 11%, P = 0.049) and a smaller %necrotic core tissue (11 ± 7 vs. 16 ± 10%, P = 0.049) compared with the non-nicorandil group. Multiple regression analysis showed that %necrotic core tissue (P = 0.045) was negatively and %fibrous tissue (P = 0.026) was positively associated with the use of nicorandil independent of statin use. We also analyzed the effect of nicorandil on atherosclerotic lesion formation in a mouse model of atherosclerosis. Lipid profiles were unaffected, but the area of atherosclerotic lesion and plaque necrosis were significantly reduced following 8-week nicorandil treatment in ApoE-deficient mice fed an atherogenic diet. Nicorandil significantly reduced the expression levels of endoplasmic reticulum stress markers, C/EBP homologous protein (CHOP) and glucose regulated protein/BiP (GRP78) in atherosclerotic lesions. Nicorandil significantly attenuated tunicamycin-induced CHOP upregulation in cultured THP-1 macrophages.. Nicorandil exerts its anti-atherogenic effect by mechanisms different from those of statins. Long-term nicorandil treatment is a potentially suitable second-line prevention therapy for patients with coronary artery disease.

Topics: Administration, Oral; Aged; Aged, 80 and over; Angina Pectoris; Animals; Aortic Diseases; Apolipoproteins E; Atherosclerosis; Cardiovascular Agents; Cells, Cultured; Chi-Square Distribution; Coronary Artery Disease; Cytokines; Disease Models, Animal; Drug Administration Schedule; Endoplasmic Reticulum; Endoplasmic Reticulum Chaperone BiP; Endothelial Cells; Fibrosis; Humans; Inflammation Mediators; Japan; Lipids; Logistic Models; Macrophages; Male; Mice; Mice, Knockout; Middle Aged; Molecular Chaperones; Necrosis; Nicorandil; Odds Ratio; Retrospective Studies; Time Factors; Treatment Outcome; Ultrasonography, Interventional

Drug eluting stents (DES) have had a great impact in reducing in-stent restenosis (ISR) in de novo lesions. However, long-term data regarding effectiveness and safety of these stents in treating bare metal stent (BMS) ISR are limited. We report long-term clinical outcomes in a cohort of patients with BMS-ISR treated with DES between April 2002 and December 2003 at our institution.. Sixty-nine consecutive patients with significant BMS-ISR were treated with DES implantation. Sirolimus DES were used in 43 patients and paclitaxel DES in 26. All patients were followed up to determine the incidence of major adverse cardiac event (MACE) rates (all-cause death, myocardial infarction, or target vessel revascularisation [TVR]), angina class and the need for clinically driven angiography. The mean age of the cohort was 58.6 ± 10.8 years; 68% were male, 33% were diabetic, 50% had hypertension, 78% were on statin therapy and 59% were current (19%) or previous (41%) smokers. The clinical presentation of ISR was with chronic stable angina in 54 patients, 12 had a non-ST elevation acute coronary syndrome and three presented with ST-elevation myocardial infarction. Multivessel stenting was performed in 21 patients and bifurcation stenting in seven patients. Over a mean follow period of 4.9 years, the first event MACE rate was 20% (17 events in 14 patients - eight deaths of which three were cardiac, two non-fatal myocardial infarctions and seven TVR). Excluding non-cardiac death, the adjusted MACE rate was 14.5% (12 events in 10 patients). At long-term follow-up, mean Canadian angina class decreased from 2.3 ± 0.7 pre-procedure to 1.2 ± 0.4, 65% of patients were angina free and 80% were free of MACE. No differences in long-term outcomes were observed between patients receiving paclitaxel and sirolimus DES.. The use of DES for the treatment of BMS-ISR is safe and effective over a mean follow-up period of nearly five years. To our knowledge, this represents the longest follow-up data of real world patients treated in a single interventional centre.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Restenosis; Disease-Free Survival; Drug-Eluting Stents; England; Female; Humans; Kaplan-Meier Estimate; Male; Metals; Middle Aged; Myocardial Infarction; Paclitaxel; Prosthesis Design; Retrospective Studies; Risk Assessment; Risk Factors; Sirolimus; Stents; Time Factors; Treatment Outcome

Although edge stenosis (ES) is a main limitation of drug-eluting stents, the predictors for ES are not well known. We evaluated the predictors for ES after paclitaxel-eluting stent implantation.. One hundred and eleven angina patients (64 men; 62.2±8.4 years of age) were divided into ES (n=9) and non-ES groups (n=102). The clinical findings, procedural factors, and intravascular ultrasound (IVUS) parameters were analyzed.. Although clinical characteristics were not different between groups, diabetes mellitus (DM) was more common in the ES group (P=0.002). The vessel, plaque, and lumen areas of the lesions were not different between groups; however, the vessel area of the proximal and distal reference artery was smaller in the ES group. Lesions with positive remodeling were more common in the ES group (P=0.015). On the basis of univariate analysis, predictors of ES included DM, lesions with positive remodeling, IVUS parameters, and procedural factors. After adjusting for clinical findings, angiographic factors, and IVUS parameters, the presence of DM [odds ratio (OR): 9.20; 95% confidence interval (CI): 1.40-60.62, P=0.021] and lesions with positive remodeling (OR: 5.93; 95% CI: 1.13-31.02, P=0.035) were independent predictors of ES. The lumen area in the distal 1 mm reference segment was a protective factor for ES (OR: 0.05; 95% CI: 0.00-0.74, P=0.029).. The risk of ES after paclitaxel-eluting stent implantation was higher in patients who had DM and lesions with positive remodeling. Of the IVUS parameters, the lumen area in the distal 1 mm reference segment was a protective factor against ES.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Diabetes Complications; Drug-Eluting Stents; Female; Humans; Logistic Models; Male; Middle Aged; Odds Ratio; Paclitaxel; Republic of Korea; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Ultrasonography, Interventional

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Vessel Anomalies; Echocardiography, Transesophageal; Electrocardiography; Exercise Test; Humans; Male; Middle Aged; Myocardial Perfusion Imaging; Predictive Value of Tests; Tomography, Emission-Computed, Single-Photon

Two hundred patients at steady-state on long-term perhexiline were identified retrospectively. The ratio of maintenance dose to steady-state plasma concentration (dose:[Px]) was correlated with the following putative determinants via simple and multiple linear regression analyses: age, weight, left ventricular ejection fraction (LVEF), and creatinine clearance (CrCl, Cockroft-Gault formula). A Mann-Whitney U test was performed to determine if severe left ventricular systolic impairment affected maintenance dose.. Advanced age, left ventricular systolic impairment, and renal impairment were frequently encountered. Using simple linear regression, age was a negative correlate of dose:[P] (R = 0.23, P = 0.001), whereas weight (R = 0.27, P = 0.0001) and CrCl (R = 0.30, P < 0.0001) were positive correlates. Mann-Whitney U analysis showed no difference between dose: [Px] among patients with LVEF of less than 30% versus 30% or greater. Advancing age was strongly associated with decreasing weight (R = -0.45, P < 0.00001) and calculated CrCl varied directly with weight, as expected (R = 0.66, P < 0.0001). Stepwise multiple linear regression using age, LVEF, CrCl, and weight as potential predictors of dose:[P] yielded only weight as a significant determinant.. Perhexiline has become a "last-line" agent for refractory angina as a result of complex pharmacokinetics and potential toxicity. Use has increased predictably in the aged and infirm who have exhausted standard medical and surgical therapeutic options. Beyond genotype, the effect of patient characteristics on maintenance dose has not been explored in detail. In this study, dose requirement declined with age in a frail and wasting population as a result of weight-related pharmacokinetic factors. LVEF had no apparent effect on maintenance dose and should not be considered a contraindication to use.. A weight-adjusted starting dose may facilitate the safe and effective prescription of perhexiline and is calculated by 50 + 2 × weight (kg) mg/d, rounded to the closest 50 mg/day.

Topics: Aged; Aged, 80 and over; Aging; Angina Pectoris; Body Weight; Cardiovascular Agents; Creatinine; Humans; Middle Aged; Perhexiline; Renal Insufficiency; Retrospective Studies; Ventricular Dysfunction, Left

Spontaneous coronary artery dissection (SCAD) is a rare cause of chest pain and cardiomyopathy. This phenomenon usually occurs during the peripartum period. SCAD associated with exercise and heavy weight lifting is even rarer and has been reported in less than 10 cases in the literature. We describe a case of SCAD associated with heavy weight lifting and exercise in a 29-year-old male who presented with exertional chest pain. The patient subsequently underwent a cardiac catheterization that showed a left ventricular ejection fraction of 40% and a dissection in the left anterior descending (LAD) coronary artery after the first diagonal/septal branch with extension to the distal LAD that wrapped around the apex. He was effectively managed with the combination of medical therapy followed by a few days later with stenting. In summary, diagnosis and treatment of this rare phenomenon is a challenge, but early diagnosis and appropriate management can lead to a successful outcome.

Topics: Adult; Angina Pectoris; Angioplasty, Balloon, Coronary; Aortic Dissection; Cardiac Catheterization; Cardiomyopathies; Cardiovascular Agents; Coronary Aneurysm; Electrocardiography; Humans; Male; Myocardial Ischemia; Stents; Stroke Volume; Treatment Outcome; Ventricular Function, Left; Weight Lifting

Self-reported angina symptoms are collected in epidemiological surveys. We aimed at validating the angina symptoms assessed by the Rose Questionnaire against registry data on coronary heart disease. A further aim was to examine the sex paradox in angina implying that women report more symptoms, whereas men have more coronary events.. Angina symptoms of 6601 employees of the City of Helsinki were examined using the postal questionnaire survey data combined with coronary heart disease registries.. The self-reported angina was classified as no symptoms, atypical pain, exertional chest pain, and stable angina symptoms. Reimbursed medications and hospital admissions were available from registries 10 years before the survey. Binomial regression analysis was used.. Stable angina symptoms were associated with hospital admissions and reimbursed medications [prevalence ratio (PR), 6.75; 95% confidence interval (CI), 4.56-9.99]. In addition, exertional chest pain (PR, 5.31; 95% CI, 3.45-8.18) was associated with coronary events. All events were more prevalent among men than women (PR, 2.36; 95% CI, 1.72-3.25).. The Rose Questionnaire remains a valid tool to distinguish healthy people from those with coronary heart disease. However, a notable part of those reporting symptoms have no confirmation of coronary heart disease in the registries. The female excess of symptoms and male excess of events may reflect inequality or delay in access to treatment, problems in identification and diagnosis, or more complex issues related to self-reported angina symptoms.

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Drug Costs; Female; Finland; Humans; Insurance, Health, Reimbursement; Male; Middle Aged; Odds Ratio; Patient Admission; Prevalence; Registries; Regression Analysis; Reproducibility of Results; ROC Curve; Self Report; Sex Distribution; Sex Factors; Surveys and Questionnaires; Time Factors

Topics: Angina Pectoris; Animals; Cardiac Catheterization; Cardiovascular Agents; Chronic Disease; Coronary Sinus; Drug Resistance; Humans; Prosthesis Design; Stents; Treatment Failure

Topics: Acute Coronary Syndrome; Angina Pectoris; Angioplasty, Balloon, Coronary; Angioscopy; Animals; Biomedical Research; Cardiac Imaging Techniques; Cardiovascular Agents; Career Choice; Coronary Artery Disease; Coronary Restenosis; Coronary Vessels; Diagnostic Imaging; Drug-Eluting Stents; Female; Humans; Male; Sirolimus; Thrombosis; Tunica Intima; Ultrasonography, Interventional

We report a case of capecitabine-induced cardiotoxicity (effort angina) in a woman with metastatic breast carcinoma. Due to cancer progression, rechallenge of therapy with capecitabine was attempted, using several strategies in order to prevent cardiotoxicity. The most (even if not fully) effective strategy was reducing capecitabine dosage together with nitrates, calcium-channel blockers and trimetazidine therapy.

Topics: Angina Pectoris; Antimetabolites, Antineoplastic; Breast Neoplasms; Capecitabine; Cardiovascular Agents; Coronary Vasospasm; Deoxycytidine; Echocardiography, Doppler, Color; Echocardiography, Doppler, Pulsed; Electrocardiography; Female; Fluorouracil; Humans; Middle Aged

Topics: Aged; Angina Pectoris; Cardiac Catheterization; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Female; Fractional Flow Reserve, Myocardial; Humans; Severity of Illness Index; Time Factors; Treatment Outcome

In the management of chronic stable angina, percutaneous coronary intervention (PCI) provides symptomatic relief of angina rather than improvement of prognosis. Current guidelines recommend optimization of medical therapy prior to elective PCI. It is not clear if these guidelines are adhered to in clinical practice.. The aim of this multi-centre study was to determine the extent to which these treatment guidelines are being implemented in the UK.. This was a multi-centre study involving six hospitals in the UK.. The medical treatment and extent of risk factor modification was recorded for consecutive patients undergoing elective PCI for chronic stable angina at each site. Data collected included anti-anginal drug therapy, lipid levels and blood pressure (BP). Data on heart rate (HR) control were also collected, since this represents a fundamental part of medical anti-anginal therapy. Target HR is <60 b.p.m. for symptomatic angina.. A total of 500 patients [74% male; mean age +/- SD (64.4 +/- 10.1 years)] were included. When considering secondary prevention, 85% were receiving a statin and 76% were on an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. In terms of medical anti-ischaemic therapy, 78% were receiving beta-blockers [mean equivalent dose of bisoprolol 3.1 mg (range 1.25-20 mg)], 11% a rate limiting calcium antagonist, 35% a nitrate or nicorandil and one patient was receiving ivabradine. The mean total cholesterol (95% confidence interval) was 4.3 mmol/l (4.2-4.4), mean systolic BP of 130 +/- 24 mmHg and mean diastolic BP of 69 +/- 13 mmHg. Serum cholesterol was <5 mmol/l in 77% and <4 mmol/l in 42% of the patients, 62% of the patients had systolic BP < 140 mmHg and 92% had diastolic BP < 90 mmHg. Considering European Society of Cardiology targets, 50% had systolic BP < 130 mmHg and 76% had diastolic BP < 80 mmHg. A large proportion of patients did not achieve target resting HR; 27% of patients had a resting HR of >or=70 b.p.m., 40% had a resting HR between 60 and 69 b.p.m. and 26% had a resting HR between 50 and 59 b.p.m. The resting HR was not related to the dose of beta-blocker.. A significant proportion of the patients with chronic stable angina undergoing elective PCI did not achieve therapeutic targets for lipid, BP and HR control. Over 50% of patients did not receive adequate HR lowering anti-anginal therapy to achieve recommended target resting HR.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Blood Pressure; Cardiovascular Agents; Chronic Disease; Female; Guideline Adherence; Heart Rate; Humans; Lipids; Male; Middle Aged; Practice Guidelines as Topic; Risk Factors; United Kingdom

A 77-year-old woman was referred to our Department of Cardiology because of exacerbation of chest pain and decreased exercise intolerance. No acute ischemic electrocardiography changes were seen in an electrocardiogram recorded on admission. An exercise test was terminated at 7 METS because of shortness of breath without evidence of ischemia. The patient was referred for a coronary angiography which showed a coronary artery fistula filling from the left anterior descending (LAD) artery and resulting in a large inflow to the main pulmonary artery, without other significant coronary lesions. Transthoracic echocardiography showed a coronary artery fistula draining to the main pulmonary artery. Coronary steal was suspected and coronary flow reserve was evaluated in LAD, showing normal values for age. Due to the overall clinical picture, with the predominance of heart failure symptoms and the lack of significant abnormalities of flow reserve in LAD, medical therapy was selected. The patient remained free from cardiovascular symptoms at 6-month follow-up.

Topics: Aged; Angina Pectoris; Arterio-Arterial Fistula; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Circulation; Echocardiography, Doppler; Electrocardiography; Exercise Test; Exercise Tolerance; Female; Humans; Myocardial Ischemia; Predictive Value of Tests; Pulmonary Artery

Topics: Allopurinol; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Enzyme Inhibitors; Humans; Trimetazidine; Vasodilator Agents

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Health Knowledge, Attitudes, Practice; Humans; Male; Orchiectomy; Piperazines; Prostate-Specific Antigen; Prostatic Neoplasms; Ranolazine; Testosterone

Topics: Aged, 80 and over; Angina Pectoris; Angioplasty; Cardiovascular Agents; Coronary Angiography; Female; Humans; Male; Quality of Life; Sex Factors

Percutaneous coronary intervention (PCI) is not associated with reduction in risk of death or myocardial infarction in patients who have chronic stable angina with normal left ventricular function and moderate coronary artery disease. A substudy of the COURAGE trial has shown that both PCI plus optimal medical therapy (OMT) and OMT alone result in marked improvements in quality of life and angina, but that PCI can substantially benefit patients with more-severe and more-frequent angina. A number of caveats to this study exist, including the extent to which the findings can be applied to the general patient population and the large proportion of patients who had mild angina or were asymptomatic--it is difficult to make these patients feel better. In addition, the remarkable commitment of both healthcare providers and patients in this study would be hard to achieve in clinical practice. Nevertheless, for patients with mild or no angina and no significant ischemia on stress testing, the COURAGE trial reassures us that OMT alone can be efficacious in reducing angina and/or improving quality of life.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Disease; Humans; Myocardial Infarction; Patient Selection; Quality of Life; Randomized Controlled Trials as Topic; Research Design; Severity of Illness Index; Treatment Outcome

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Disease; Humans; Myocardial Infarction; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Research Design; Time Factors; Treatment Outcome

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Atenolol; Benzazepines; Cardiovascular Agents; Drug Therapy, Combination; Humans; Ivabradine; Treatment Outcome

Therapeutic options for patients with recurrent cardiac ischemia after coronary artery bypass surgery may be limited and some patients may be considered nonrevascularizable. To further the understanding of this patient cohort, we performed a population-based study of post-coronary bypass patients who developed recurrent angina.. Patients who underwent coronary artery and bypass graft angiography at Mayo Clinic from 2001 to 2005 were identified. Medical records were reviewed to determine indication for angiography, and angiographic analysis was performed in all patients. Among 133 000 residents of Olmsted County, Minnesota, 347 post-bypass patients with angina underwent coronary angiography from 2001 to 2005. Of these, 177 patients received further revascularization (145 percutaneous coronary intervention and 32 redo coronary artery bypass grafting) and the remaining 170 patients were managed medically. Revascularization was not associated with improvement in all-cause or cardiac mortality. Multivariate analysis identified renal dysfunction, diabetes, and severe left ventricular dysfunction but not the lack of revascularization as predictors of mortality.. In this population-based study, we identified a yearly incidence range of 17.9-33.2 patients with nonrevascularizable angina after coronary artery bypass grafting per 100 000 population. Further revascularization was not associated with improved mortality or morbidity. Attempts to develop therapeutics for this population must consider the incidence and outcomes of this cohort.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Minnesota; Population Surveillance; Proportional Hazards Models; Prospective Studies; Recurrence; Reoperation; Risk Assessment; Risk Factors; Time Factors; Treatment Failure

Methylphenidate is a potent central nervous system stimulant that exerts its effects by increasing synaptic levels of dopamine and norepinephrine. It has become key to treating attention deficit-hyperactivity disorder (ADHD) in children and adolescents. As the use of stimulant medications has ballooned in the past decade, so too has awareness of the cardiovascular complications of these drugs. Effects on heart rate and blood pressure as well as tachyarrhythmias have been well described. However, acute cardiomyopathy and pericarditis secondary to methylphenidate use has been rarely reported. We report the case of a 17-year-old male who developed chest pain, elevated cardiac biomarkers, and acute left ventricular dysfunction following a single dose of methylphenidate. The risk of cardiomyopathy in the setting of methylphenidate treatment should prompt further study on the safety of this drug, and lead to ways of identifying those at risk of developing these complications.

Topics: Acute Disease; Adolescent; Angina Pectoris; Attention Deficit Disorder with Hyperactivity; Cardiomyopathies; Cardiovascular Agents; Central Nervous System Stimulants; Drug Therapy, Combination; Electrocardiography; Humans; Male; Methylphenidate; Pericarditis; Ventricular Dysfunction, Left

We describe two cases of severe, multivessel coronary vasospasm that occurred a few months after placement of sirolimus-eluting stents in patients with severe coronary disease, and involved segments not significantly atheromatous and not previously treated. The literature suggests that biocellular interference with the endothelial equilibrium on the part of drugs eluted from a stent poses a serious risk of tardive and widespread postangioplasty coronary spasm in comparison with the use of a bare-metal stent.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Stenosis; Coronary Vasospasm; Drug-Eluting Stents; Humans; Intra-Aortic Balloon Pumping; Male; Middle Aged; Prosthesis Design; Severity of Illness Index; Sirolimus; Time Factors; Treatment Outcome; Vasodilator Agents

The study aimed to compare the clinical picture and treatment differences in elderly patients (aged 75 years or older) and younger patients (aged below 75 years).. The study included 80 consecutive patients with myocardial infarction (MI) treated in the Cardiology Ward of the Specialist Hospital in Radom, Poland, in 2005. Analyses were performed retrospectively. The patients were separated into 2 groups according to age. The group I study group consisted of 40 patients aged 75 or over (aged 75-95; mean 81 years) and the group II control group consisted of 40 patients aged below 75 years (aged 42-67; mean 60 years).. In the elderly, as compared with younger subjects, dyspnea, fatigue, and other heart failure symptoms, were more frequently the first symptoms of MI than typical chest pain (p<0.05). ST-segment elevation myocardial infarction (STEMI) was also more common (p<0.05). Non-ST-segment elevation myocardial infarction (NSTEMI) was more frequently diagnosed in the elderly (p<0.05). In elderly patients there were more women (p<0.05), more patients with previously diagnosed ischemic heart disease (p<0.05), with hypertension (p<0.05), and with diabetes mellitus (p<0.05). Obesity was less frequently diagnosed in the elderly; however the difference was not statistically significant. Dyslipidemia and cigarette smoking were both significantly less common among elderly patients (p<0.05). The elderly were significantly less frequently revascularized (p<0.05). Both fibrinolysis and primary percutaneous coronary intervention (PCI) were less commonly applied to the elderly (p<0.05). Time from symptom onset to hospital admission was significantly longer in the case of elderly patients (p<0.05). The MI complications and side effects of treatment seemed to be more frequent in the elderly, but only post-MI heart failure was observed more frequently in this group of patients (p<0.05).. Our observations confirm the differences in the clinical picture of MI in the elderly as described previously. All patients of advanced age should be considered as having the highest risk of death and complications occurrence.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Dyspnea; Fatigue; Female; Heart Failure; Humans; Male; Middle Aged; Myocardial Infarction; Poland; Retrospective Studies; Risk Assessment; Risk Factors; Thrombolytic Therapy; Time Factors; Treatment Outcome

A 60-year-old man who had serious chest and arm pain died suddenly during hospitalization. He suffered from coronary vasospastic angina complicated by a fatal acute fulminant-type of myocarditis associated with Churg-Strauss syndrome (CSS). The diagnosis at autopsy was acute progressive eosinophilic myocarditis associated with CSS.

Topics: Angina Pectoris; Autopsy; Cardiovascular Agents; Churg-Strauss Syndrome; Coronary Angiography; Coronary Vasospasm; Death, Sudden, Cardiac; Electrocardiography; Eosinophilia; Fatal Outcome; Humans; Male; Middle Aged; Myocarditis

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial confirmed that percutaneous coronary intervention is no better than optimal medical therapy for the prevention of major adverse cardiac events in patients with stable angina. The impact of these findings on clinical practice remains unknown.. Clinicians may more frequently opt for medical rather than procedural therapy of stable angina in response to the COURAGE trial.. Clinical information was collected from patients with stable angina referred to our hospital for cardiac catheterization between January 1, 2007 and June 18, 2007 (n = 332). Catheterization referral volume and the use of medications and coronary revascularization were compared before and after the release of the COURAGE trial.. There was a significant increase in anti-ischemia medication use prior to catheterization referral following the COURAGE trial (mean = 1.31 [SD 0.83] medications pre-COURAGE, mean = 1.54 [SD 0.84] medications post-COURAGE, P = 0.012). Among 217 patients with coronary disease on catheterization, treatment with medication rather than percutaneous or surgical revascularization increased after COURAGE (11.1% pre-COURAGE vs 23.0% post-COURAGE, P = 0.03). There was also a significant decrease in referral volume following the COURAGE trial (3.12 referrals/day pre-COURAGE vs 2.51 referrals/day post-COURAGE, P = 0.034).. The COURAGE trial immediately impacted the management of stable angina. Catheterization referral volume decreased, medication use increased, and the use of medical therapy rather than revascularization increased among patients with coronary disease.

Topics: Academic Medical Centers; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Drug Utilization; Evidence-Based Medicine; Female; Humans; Male; Middle Aged; Patient Selection; Practice Patterns, Physicians'; Referral and Consultation; Retrospective Studies; Time Factors; Treatment Outcome

We aimed to evaluate the risk of definite stent thrombosis with bare-metal stents (BMS) and drug-eluting stents (DES) in patients treated for acute coronary syndromes.. Acute coronary syndromes (ACS) have been reported as increasing the risk for stent thrombosis.. Between January 2000 and December 2005, 5,816 consecutive patients underwent percutaneous coronary intervention for de novo lesions with a single stent type. These patients consisted of 3 sequential groups of BMS (n = 2,248), sirolimus-eluting stents (n = 822) and paclitaxel-eluting stents (n = 2,746). In total, 3,485 patients presented with an ACS.. After a median follow-up of 1,394 days, patients with ACS had a definite stent thrombosis rate of 2.5% versus 1.0% in patients with stable angina (propensity score-adjusted hazard ratio [HR]: 2.80, 95% confidence interval [CI]: 1.72 to 4.56). ACS patients had a higher risk of early and late stent thrombosis, although the increased risk of very late stent thrombosis was only present in ACS patients treated with DES. In stable patients, any stent thrombosis resulted in a significant increase in mortality (adjusted HR: 4.0, 95% CI: 1.7 to 9.3), although this was particularly evident for late or very late stent thrombosis; in contrast only early stent thrombosis significantly increased mortality in patients with acute coronary syndrome patients (adjusted HR: 2.0, 95% CI: 1.0 to 4.1).. Patients with acute coronary syndromes are at higher risk of early and late stent thrombosis with either BMS or DES, although very late stent thrombosis seems to be uniquely associated with DES. The clinical sequelae of late and very late stent thrombosis are more pronounced in stable patients.

Topics: Acute Coronary Syndrome; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Drug-Eluting Stents; Female; Humans; Kaplan-Meier Estimate; Male; Metals; Middle Aged; Paclitaxel; Proportional Hazards Models; Prosthesis Design; Registries; Risk Assessment; Risk Factors; Sirolimus; Stents; Thrombosis; Time Factors; Treatment Outcome

The objective of this study is to report on our 5-year collective experience on the use of perhexiline in the UK, in patients with chronic heart failure (CHF) and/or refractory angina with respect to 'real-life' drug side effects and toxicity, therapeutic drug level monitoring, 5 year mortality outcomes and predictors of response to perhexiline therapy.. Data on clinical history, perhexiline monitoring, follow-up, and mortality were retrospectively collated from centralized perhexiline databases from two tertiary referral centres. A total of 151 patients were on perhexiline therapy at two UK tertiary referral centres. At 3-4 months, 68.8% of patients had drug level within the therapeutic range and 20.8% were above the therapeutic range. A total of 58.9% of patients reported to have felt better on the perhexiline (responders). The presence of refractory angina was an independent predictor of response to perhexiline therapy (odds ratio 2.84, 95% confidence interval 1.28-6.32, P = 0.01). Five-year mortality was non-significantly different between patients with refractory angina, CHF, or both (20.5, 31.0, and 38.4%, P = 0.20, respectively).. Perhexiline therapy provides symptomatic relief in the majority of patients with minimal side effects or toxicity. Careful therapeutic level monitoring for dose titration is important to prevent acute and chronic toxicity. Patients with refractory angina were more likely to be responders.

Topics: Aged; Analysis of Variance; Angina Pectoris; Cardiovascular Agents; Confidence Intervals; Drug Monitoring; Female; Health Status Indicators; Humans; Logistic Models; Male; Odds Ratio; Perhexiline; Proportional Hazards Models; Prospective Studies; Time Factors; Treatment Failure; Vasodilator Agents

Topics: Angina Pectoris; Animals; Blood Flow Velocity; Cardiovascular Agents; Chest Pain; Coronary Circulation; Coronary Disease; Diagnosis, Differential; Humans; Mibefradil; Quality of Life; Randomized Controlled Trials as Topic; Rest; Vasodilator Agents

The aim of this study was to investigate the long-term prognosis of non-interventionally followed patients with myocardial bridge and angiographic milking of the left anterior descending (LAD) coronary artery.. All of the coronary angiography records from May 2000 to November 2007 were reevaluated and patients who had more than 70% narrowing during systole on LAD were eligible for the present study. Follow-up was carried out by physical examination, echocardiography, and treadmill exercise testing. The clinical situations of the patients, medical treatment at the time of follow-up, and experienced events (death, myocardial infarction, or revascularization) were recorded.. There were 59 eligible patients (44 male, 74.6%). The mean age of the patients was 54 +/- 11 years. The bridges were located in the proximal, mid, and distal portion of the LAD in 17 (28.8%), 20 (33.9%), and 22 (37.3%) patients, respectively. Distributions of the narrowing degree were as follows: between 70% to 89% in 33 (56%) patients and 90% to 100% in 26 (44%) patients. Mean follow-up duration of the group was 37 +/- 13 months (range 15-65 mo). The clinical presentation during follow-up was stable angina in 9 (15.3%) cases, atypical angina in 12 (20.3%), atypical chest pain in 13 (22%), dyspnea in 3 (5.1%), and syncope in 3 (5.1%) cases. There were no experienced events and/or hospitalizations related to cardiac disease. Echocardiographic examination revealed normal systolic ventricular function. Only 17 (28.8%) patients continued to use medication. Most of them were on beta-blocker therapy.. Patients with myocardial bridges and angiographic milking of the LAD coronary artery have a good long-term prognosis.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Cineangiography; Coronary Angiography; Coronary Stenosis; Dyspnea; Echocardiography; Exercise Test; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Bridging; Myocardial Ischemia; Registries; Severity of Illness Index; Syncope; Time Factors; Treatment Outcome

Sirolimus-eluting stent (SES) has revolutionized interventional cardiology. Its application is spreading to complex, high-risk subsets of patients and lesions. Therefore, it is important to determine the factors associated with post-SES restenosis.. The study investigated 341 patients with angina pectoris, in whom SES was implanted. The coronary artery calcification (CAC) degree was assessed using the angiographic scoring system as follows: 0, none; 1, blocky or spotty calcification; 2, linear calcification compromising 1 side of the arterial lumen; 3, linear calcification found unidirectionally compromising both sides of the arterial lumen; 4, linear calcification found bidirectionally compromising both sides of the arterial lumen; and 5, blanket/circumferential and dense calcification. Restenosis was observed in 23 patients (7.3%). The target lesion (1.8 +/-1.7 vs 0.7 +/-1.1 [mean +/- SD]) and stent delivery route CAC scores (3.1 +/-2.5 vs 1.4 +/-2.0) were significantly higher in patients with restenosis than in those without it (P<0.0001). In multivariate analysis, the CAC score of the stent delivery route was independently associated with restenosis (odds ratio of 6.804, P<0.05), although CAC score of the target lesion was not.. CAC in the stent delivery route is an important determinant of post-SES restenosis.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Angioplasty, Balloon, Coronary; Calcinosis; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Restenosis; Drug-Eluting Stents; Female; Humans; Male; Microscopy, Electron; Middle Aged; Odds Ratio; Prosthesis Failure; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Sirolimus; Treatment Outcome

The aim of the present study was to compare the effects of drug-eluting stents (DES) and coronary artery bypass grafting (CABG) in patients suffering from chronic stable angina with multivessel disease, involving significant proximal stenosis in the left anterior descending artery (LAD).. All consecutive patients suffering from chronic stable angina with multivessel disease involving significant proximal LAD stenosis underwent DES implantation (n=600) or CABG (n=709) at our institution. At 2 years, the unadjusted mortality was significantly lower in the DES group than in the CABG group (2.2% vs 5.2%, P=0.004), but the adjusted risk of death was similar (odds ratio (OR) 0.74, 95%CI 0.28-1.97, P=0.555). Furthermore, both the adjusted rate of nonfatal myocardial infarction and cerebrovascular events was also comparable. However, the unadjusted and adjusted risk of major adverse cardiac cerebrovascular events in the DES was significantly higher than in the CABG (13.3% vs 9.6%, OR 2.71, 95%CI 1.56-4.74, P<0.001), which is probably attributed to the higher subsequent revascularization rate after DES implantation.. DES showed comparable long-term mortality for the treatment of multivessel disease involving significant proximal stenosis in LAD in comparison with CABG.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Cerebrovascular Disorders; Chronic Disease; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Drug-Eluting Stents; Female; Hospital Mortality; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Myocardial Infarction; Odds Ratio; Paclitaxel; Platelet Aggregation Inhibitors; Proportional Hazards Models; Registries; Reoperation; Retrospective Studies; Risk Assessment; Severity of Illness Index; Sirolimus; Time Factors; Treatment Outcome

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Humans; Myocardial Ischemia

Slow coronary flow is an angiographic phenomenon characterized by delayed opacification of vessels in the absence of any evidence of obstructive epicardial coronary disease. In this article, we present serious clinical manifestations of extremely slow coronary flow in two hypertensive patients with preserved ejection fraction in echocardiographical examination: a 57 year-old woman with acute coronary syndrome and temporary ST elevation; and a 65 year-old man with atrial tachycardia which was leading to sudden arrest of circulation. The woman was admitted to hospital due to recurrent syncope and chest pain. Because of severe bradycardia, an AAI pacemaker was implanted. Coronary angiography without evident obstructive lesion revealed extremely slow flow of dye through arteries. The man was admitted to hospital because of heart palpitations (paroxysmal atrial tachycardia, PAT) followed by chest pain. During hospitalization, a sudden arrest of circulation in the course of supraventricular tachycardia of 220/min with atrioventricular conduction of 1:1 occurred. Coronary arteriography did not show any occlusions in the coronary arteries, although extremely slow dye flow was seen. Electrophysiological examination revealed arrhythmia of the left atrial (PAT) (tricuspid valve anulus mapping) without induced ventricular arrhythmia. Because of symptomatic bradyarrhythmia, a VVI heart pacemaker was implanted. Over a 12-month observation, his heart rate remained under control, and the patient did not complain of chest pains or heart palpitations.

Topics: Acute Coronary Syndrome; Aged; Angina Pectoris; Blood Flow Velocity; Bradycardia; Cardiac Pacing, Artificial; Cardiovascular Agents; Combined Modality Therapy; Coronary Angiography; Coronary Circulation; Coronary Disease; Drug Therapy, Combination; Electrocardiography; Female; Heart Rate; Humans; Male; Middle Aged; Syncope; Tachycardia, Paroxysmal; Tachycardia, Supraventricular; Treatment Outcome

Although antianginal drugs are used over several months and through to years in stable angina, there is scant evidence regarding their influence on outcomes. The METRO (ManagEment of angina: a reTRospective cOhort) study sought to assess the independent effect of using these drugs on subsequent mortality risk in patients with stable angina.. Consecutive patients with stable angina, receiving at least one antianginal drug (nitrates, beta-adrenoceptor antagonists, calcium channel antagonists, trimetazidine, or nicorandil), were selected if they were discharged alive from an intensive care unit following a myocardial infarction (MI). Their case-record data were used in a multivariate logistic regression model to examine the independent association of antianginal drug use prior to the MI with predicted post-discharge, 6-month, all-cause mortality risk.. In 353 patients, of whom 287 (81.3%) were men, the mean (+/- SD) age was 55 (+/- 10.2) years and duration of treated stable angina was 27.2 (+/- 24.8) months. The odds ratios (95% CI) of 6-month, all-cause mortality after surviving an MI were: for treatment that included a beta-adrenoceptor antagonist, 0.63 (0.26, 1.52; p = 0.309); a calcium channel antagonist, 0.76 (0.12, 2.89; p = 0.638); a nitrate, 0.52 (0.26, 1.05; p = 0.070); nicorandil, 0.62 (0.29, 1.33; p = 0.221); and trimetazidine, 0.36 (0.15, 0.86; p = 0.022).. The inclusion of trimetazidine in the antianginal treatment of stable angina is independently associated with a significant reduction in mortality after surviving an MI. This suggests that combining a metabolic agent with drugs that modulate oxygen supply and demand, early in the management of stable angina, may confer a survival benefit.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Female; Humans; Logistic Models; Male; Middle Aged; Models, Statistical; Myocardial Infarction; Odds Ratio; Retrospective Studies; Risk; Survival; Treatment Outcome

Takayasu arteritis is a chronic, progressive, autoimmune, idiopathic, large-vessel vasculitis that usually affects young adults. The disease has been reported to occur in all races and ethnicities. The diffuse nature of this vasculitis can affect multiple-organ systems to varying degrees. Herein, we report the case of a young woman whose exertional angina and claudication were the initial presentation of active Takayasu arteritis. During more than 4 years of ongoing treatment, therapy, and follow-up, she has displayed differing disease symptoms of varying intensity. We discuss the challenges of managing Takayasu arteritis in our patient and describe different treatments for this rare vasculitic disorder.

Topics: Adult; Angina Pectoris; Aortography; Arterial Occlusive Diseases; Cardiovascular Agents; Combined Modality Therapy; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Exercise Test; Female; Humans; Immunosuppressive Agents; Intermittent Claudication; Magnetic Resonance Angiography; Severity of Illness Index; Takayasu Arteritis; Treatment Outcome

We report the case of a 75-year-old woman who presented with stable angina and with a quadricuspid aortic valve, which consisted of 4 equal-sized leaflets that were diagnosed incidentally upon coronary angiography. Despite the patient's advanced age, the abnormal valve was functioning almost normally.

Topics: Aged; Angina Pectoris; Aortic Valve; Cardiovascular Agents; Coronary Angiography; Coronary Stenosis; Female; Humans; Incidental Findings

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Coronary Circulation; Exercise Test; Humans; Myocardial Ischemia; Myocardial Perfusion Imaging; Oxygen Consumption; Piperazines; Ranolazine; Severity of Illness Index; Tomography, Emission-Computed, Single-Photon; Treatment Outcome

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Humans; Meta-Analysis as Topic; Risk Factors; Risk Reduction Behavior

Drug-eluting stents were developed and approved for the reduction of in-stent restenosis. However, restenosis still occurs, and stent fracture is suggested as a cause of restenosis after implantation. Although sirolimus-eluting stents are considered to carry a high risk of fracture, the risk is also present with other drug-eluting stents. Herein, we report the case of a 78-year-old woman who received a zotarolimus-eluting stent for a bifurcation lesion of the left anterior descending coronary artery. Ten months later, she underwent coronary angiography due to angina. The angiogram revealed in-stent restenosis, with a grade IV stent fracture. After percutaneous coronary angioplasty, the patient's clinical symptoms improved.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Restenosis; Drug-Eluting Stents; Female; Humans; Prosthesis Failure; Sirolimus; Treatment Outcome

Retrospective analysis of the prescribing practice and cost of ambulatory treatment of hypertension and its common complications--heart failure, sequelae of cerebrovascular disease, and angina pectoris.. Analysis of 3,240 reimbursable ambulatory prescriptions for hypertension, heart failure, sequelae of cerebrovascular disease and angina pectoris according to the complexity of the therapy and frequency of the prescribed medicines. Modeling and calculation of the expected monthly cost for outpatient therapy by using the "decision tree model". Sensitivity analysis is performed within the +/- 30% interval.. 65% of the prescription were for the hypertension, and 35% for the observed complications. 1,297 prescriptions for hypertension include one medicine, 647 include two medicines, and only 8% of prescriptions were for three medicines. ACE inhibitors have been prescribed in 41% of all hypertension prescriptions, followed by beta-blockers (19%), Ca channel blockers (16%), diuretics (15%) etc. The prescriptions for hypertension complications are more diverse as therapeutic groups. The expected monthly cost of prescribed medicines per patient with hypertension alone is 6.90 Euro and in case of complications it is 10.71 Euro according to the prevalence of the complexity of therapy, and weighted monthly cost of medicines. The overall ambulatory cost is expected to be around 148 million Euro per year for near 1.5 million patients with 44% reimbursement. The cost of the therapy is sensitive more to changes in the medicine's prices than to its complexity.. This study is a first step in providing information for evidence-based cost containment measures or policy decisions at ambulatory level in Bulgaria and for the assessment of the share of complications' therapy on the overall hypertension cost.

Topics: Ambulatory Care; Angina Pectoris; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Decision Trees; Drug Therapy, Combination; Drug Utilization; Heart Failure; Humans; Hypertension; Practice Patterns, Physicians'; Prescription Fees; Retrospective Studies

Tako-tsubo cardiomyopathy has been gradually recognized worldwide. However, medications for the prevention remain not to be investigated in part because the precise mechanism is unclear. We sought to examine medications before the onset of tako-tsubo cardiomyopathy, and to prove the limitation of these medications for the prevention.. This study consisted of 21 patients with tako-tsubo cardiomyopathy who received one or more medications for hypertension or suspected angina pectoris. Each patient was assessed with history, medications, coronary angiography and left ventriculography. All patients but 1 were female, and age ranged 41 to 87 years (73+/-11 years). Twelve patients received calcium channel blockers, 7 patients received nitrates, and one patient received beta blocker. Three patients received angiotensin coverting enzyme inhibitors, and 4 patients received angiotensin II receptor blockers. One patient died of serious pneumonia, but there was no patient who died of tako-tsubo cardiomyopathy itself. During the 3 year follow-up, one patient receiving angiotensin receptor blocker had the recurrence of tako-tsubo cardiomyopathy due to recurrent epileptic seizure.. Tako-tsubo cardiomyopathy can occur despite treatment with calcium channel blockers, nitrates or beta-blockers, suggesting limitation of these medications to prevent tako-tsubo cardiomyopathy.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Female; Follow-Up Studies; Humans; Hypertension; Male; Middle Aged; Pharmaceutical Preparations; Takotsubo Cardiomyopathy

The management of chronic stable angina has undergone considerable evolution over the past two decades. This article highlights the need for a comprehensive approach to management that includes carefully identifying cardiac risk factors, using therapeutic lifestyle interventions, aggressive, multifaceted medical therapy, and judiciously using myocardial revascularization. For patients whose ischemia cannot be optimally controlled with traditional anti-ischemic agents, a novel antianginal and anti-ischemic agent (ie, ranolazine) has promise in reducing refractory ischemia as add-on therapy. This article discusses the role of coronary artery bypass graft surgery and percutaneous coronary intervention (PCI) in managing chronic stable angina patients and the clinical implications of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation) trial. The combined use of a "focal" approach (PCI to treat the culprit stenosis) and a "systemic" approach (lifestyle intervention and aggressive pharmacotherapy) may afford the best event-free survival and clinical outcomes in patients with stable angina.

Topics: Acetanilides; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Chronic Disease; Combined Modality Therapy; Coronary Artery Bypass; Disease-Free Survival; Enzyme Inhibitors; Humans; Piperazines; Platelet Aggregation Inhibitors; Ranolazine; Risk Factors; Risk Reduction Behavior

Isolated single coronary artery (SCA) is an extremely rare congenital coronary anomaly. Some subgroups of SCA can lead to angina pectoris, acute myocardial infarction or even sudden death in the absence of atherosclerosis. Young patients, especially, have the risk of serious clinical events, but middle-aged-to elderly patients have a variable clinical course.. The aim of this study was to present the clinical and angiographic properties, relatively long-term follow-up (54+/-14 months) and management of adult patients (mean age 57+/-12 years) with SCA. The records of 70,850 patients undergoing coronary angiography between 1999 and 2005 were reviewed. Ten patients (0.024%) were found to have SCA, originating from the left sinus of Valsalva in 3 (30%) patients and from the right sinus of Valsalva in 7 patients (70%). No atherosclerotic involvement was seen in 7 (70%) patients. One patient was also treated by stent implantation to the SCA. Other patients were followed medically. All patients have been followed uneventfully.. Medical treatment is usually adequate for middle-aged to elderly patients with SCA in the absence of ischemia and/or acute coronary syndrome.

Topics: Adult; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Vessel Anomalies; Coronary Vessels; Female; Humans; Male; Middle Aged; Retrospective Studies; Sinus of Valsalva; Stents; Time Factors; Treatment Outcome; Turkey

Doctor: "Ma'am you need an angioplasty".. "Doctor, the newspaper says that medicine is as good as angioplasty". Doctor: "Ma'am you're having a heart attack". The COURAGE trial was published 1 year ago and received attention from the media, patients, and other medical specialties concerning the value of percutaneous coronary intervention. Now, 1 year later there has been time to reflect on COURAGE, and some newer data have emerged. The purpose of this article is to put into perspective the issues surrounding the COURAGE trial and suggest different approaches for future trials of stable coronary artery disease.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Disease; Humans; Multicenter Studies as Topic; Myocardial Infarction; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Research Design; Time Factors; Treatment Outcome

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Angioplasty, Balloon; Angiotensin II Type 1 Receptor Blockers; Calcium Channel Blockers; Cardiovascular Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Nitrates

The aim of the present study was to compare lesion morphologies after sirolimus-eluting stent (SES) implantation between patients with unstable angina pectoris (UAP) and stable angina pectoris (SAP) with the use of optical coherence tomography (OCT).. The lesion morphologies before and after coronary stenting have been proposed as important predictors of clinical outcome. The high resolution of OCT provides detailed information of coronary vessel wall.. We enrolled 55 patients (UAP: n = 24, SAP: n = 31), and examined lesion morphologies by using OCT at pre- and post-SES implantation and 9 months' follow-up.. The incidence of plaque rupture (42% vs. 3%, p < 0.001), intracoronary thrombus (67% vs. 3%, p < or = 0.001) and thin-capped fibroatheroma (cap thickness <65 microm; 46% vs. 3%, p < 0.001) at pre-intervention was significantly greater in UAP than that in SAP. Although stent profiles and procedural characteristics were not different between the 2 groups, inadequate stent apposition (67% vs. 32%, p = 0.038) and tissue protrusion (79% vs. 42%, p = 0.005) after percutaneous coronary intervention were observed more frequently in patients with UAP. Plaque rupture was significantly increased after percutaneous coronary intervention in patients with UAP (42% to 75%, p = 0.018), and the persistence of core cavity after plaque rupture (28% vs. 4%, p = 0.031) at 9 months' follow-up was observed more frequently in UAP patients compared with SAP patients. At 9 months' follow-up, the incidence of inadequately apposed stent (33% vs. 4%, p = 0.012) and partially uncovered stent by neointima (72% vs. 37%, p = 0.019) was significantly greater in UAP patients than that in SAP patients. All patients took aspirin and ticlopidine during follow-up period, and no patients had stent thrombosis or adverse coronary events.. Serial OCT examinations demonstrated markedly different vascular response up to 9 months after SES implantation between UAP and SAP patients. Although the inadequate lesion morphologies after stenting were observed more frequently in UAP patients, these findings were not associated with adverse outcomes in patients with antiplatelet therapy.

Topics: Aged; Angina Pectoris; Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Vessels; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Observer Variation; Platelet Aggregation Inhibitors; Predictive Value of Tests; Prospective Studies; Rupture; Sirolimus; Thrombosis; Time Factors; Tomography, Optical Coherence; Treatment Outcome

Topics: Angina Pectoris; Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Vessels; Drug-Eluting Stents; Humans; Platelet Aggregation Inhibitors; Predictive Value of Tests; Rupture; Sirolimus; Thrombosis; Time Factors; Tomography, Optical Coherence; Treatment Outcome; Wound Healing

Topics: Acute Coronary Syndrome; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Disease; Humans; Incidence; Patient Selection; Risk Assessment; Severity of Illness Index; Time Factors; Treatment Outcome

Variations in the resources, stability and priorities of health care systems conceivably affect their capacity to implement health care reform and ensure an evidence based approach to health care. Such variation may partially account for differences in cardiovascular mortality rates between former communist states in Central Europe and Western European countries, but specific data on this subject is sparse. The aim of this study was to compare the presentation of stable angina to cardiology services in Poland vs. the United Kingdom, the management of the condition in relation to existing European guidelines and clinical outcome.. Data was collected as part of a prospective observational cohort study of stable angina in Europe. Information was recorded on referral patterns, clinical presentation and the use of pharmacological therapies, investigations, revascularisation and cardiovascular events during 1 year of follow up. A total of 571 patients with stable angina were enrolled in Poland and 319 in the UK. Patients presenting to cardiology services in Poland were less likely to be referred by a primary care physician, younger, and had more adverse clinical risk predictors at presentation. Non-invasive investigation and coronary angiography were performed less frequently in Poland, but waiting times for invasive assessment were shorter. European guidelines with regard to the use of evidence based secondary preventative medical therapy were applied widely by cardiologists in both countries. No differences were observed in rates of cardiovascular events.. The use of evidence based pharmacological therapy was equally high in both countries, but guidelines regarding investigation were less completely adhered to in Poland, where invasive assessment and subsequent management was prompt but only performed in a highly selected proportion of the population with stable angina.

Topics: Age Distribution; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Circulation; Drug Utilization; Electrocardiography; Exercise Test; Female; Follow-Up Studies; Guideline Adherence; Heart Failure; Humans; Hyperlipidemias; Hypertension; Male; Middle Aged; Myocardial Revascularization; Peripheral Vascular Diseases; Poland; Practice Guidelines as Topic; Primary Health Care; Prospective Studies; Referral and Consultation; Sex Distribution; United Kingdom

Ranolazine is a piperazine derivative believed to reduce anginal symptoms by preventing ischemia-mediated sodium and calcium overload in myocardial cells through inhibition of the late sodium current (late INa). Three small studies demonstrated the antianginal efficacy of ranolazine alone and in combination with betablockers or calcium channel blockers on conventional end points such as total exercise duration and time to ischemia/angina on a treadmill; however, questions of safety related to QT prolongation, efficacy in women and potential utility in higher risk populations remained. Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST Elevation Acute Coronary Syndromes-Thrombolysis in Myocardial Infarction (MERLIN-TIMI) 36 was a large randomized, double-blind, placebo-controlled trial, which evaluated the efficacy and safety of ranolazine initiated acutely and continued as chronic therapy following a non-ST-segment elevation acute coronary syndrome event. A total of 6560 patients were randomized 1:1 to ranolazine or placebo; the primary efficacy end point of the trial was a composite of cardiovascular death, myocardial infarction or recurrent ischemia. The key safety end points were death from any cause and symptomatic documented arrhythmia. Although statistically significant differences between the ranolazine and placebo groups were not reached in the primary efficacy analysis or in the major secondary outcome end point analyses (cardiovascular death, myocardial infarction or severe recurrent ischemia), the individual component of recurrent ischemia was significantly reduced by ranolazine, and ranolazine was demonstrated to be safe.

Topics: Acetanilides; Acute Coronary Syndrome; Acute Disease; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Double-Blind Method; Drug Therapy, Combination; Enzyme Inhibitors; Female; Humans; Male; Middle Aged; Myocardial Infarction; Piperazines; Quality of Life; Randomized Controlled Trials as Topic; Ranolazine; Recurrence; Sex Factors; Thrombolytic Therapy

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Confounding Factors, Epidemiologic; Coronary Stenosis; Humans; Patient Selection; Randomized Controlled Trials as Topic; Research Design; Risk Factors; Vasodilator Agents

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Stenosis; Fractional Flow Reserve, Myocardial; Humans; Myocardial Infarction; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Time Factors; Treatment Outcome

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Niacin; Randomized Controlled Trials as Topic; Treatment Outcome; Vasodilator Agents

This report describes the prompt resolution of an apical left ventricular (LV)-thrombus complicating transient apical ballooning in a 74-year-old woman. The patient was admitted to our emergency department with acute chest pain and ST-elevation on the electrocardiogram. Coronary angiography showed normal coronary arteries and LV-angiography demonstrated the presence of apical ballooning akinesis associated with basal hypercontraction. Echocardiography and MRI studies confirmed the presence of LV-apex akinesis and detected an apical thrombus. Follow-up echocardiography on day 12 before discharge of the patient, revealed a marked improvement of regional contractility of the LV-apex and surprisingly the complete resolution of the LV-apical thrombus. The patient was diagnosed with takotsubo cardiomyopathy.

Topics: Aged; Angina Pectoris; Anticoagulants; Cardiomyopathies; Cardiovascular Agents; Female; Heart Diseases; Humans; Remission Induction; Thrombosis; Ventricular Dysfunction, Left

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Coronary Artery Bypass; Coronary Disease; Endpoint Determination; Follow-Up Studies; Humans; Myocardial Infarction; Prognosis; Research Design; Sample Size; Stents; Treatment Outcome

Topics: Adult; Angina Pectoris; Anticoagulants; Biopsy; Cardiovascular Agents; Endocardium; Heart Diseases; Heart Failure; Humans; Magnetic Resonance Imaging; Male; Myocarditis; Parvoviridae Infections; Parvovirus B19, Human; Thrombosis

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Enzyme Inhibitors; Humans; Myocardial Infarction; Piperazines; Ranolazine

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Biomarkers; Cardiology; Cardiovascular Agents; Heart Failure; Heart Transplantation; History, 20th Century; History, 21st Century; Humans; Hungary; Myocardial Infarction; Myocardial Ischemia; Severity of Illness Index; Thrombolytic Therapy

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Disease; Humans; Life Style; Myocardial Infarction; Randomized Controlled Trials as Topic

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiac Catheterization; Cardiovascular Agents; Clinical Trials as Topic; Coronary Disease; Coronary Stenosis; Cost-Benefit Analysis; Humans; Myocardial Infarction; Quality-Adjusted Life Years; Stents

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Diet; Exercise; Humans; Hypolipidemic Agents; Life Style

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Diet; Exercise; Humans; Hypolipidemic Agents; Life Style

Stress cardiomyopathy is a reversible left ventricular dysfunction precipitated by emotional stress. Affected patients are generally women, whose symptoms are similar to myocardial infarction with reversible apical dyskinesis associated with hypercontractile basal segments and no evidence for hemodynamically significant coronary arterial stenoses by angiography. We report the case of an 82-year-old woman who presented with acute onset of chest pain after emotional stress and with reversible left ventricular dysfunction consisting of akinesis of the midventricular segments and hyperkinesis of the basal and apical segments.

Topics: Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Echocardiography, Four-Dimensional; Electrocardiography; Female; Humans; Myocardial Contraction; Takotsubo Cardiomyopathy; Treatment Outcome; Ventricular Dysfunction, Left

Registry patients are generally older and more sick than patients enrolled in trials questioning the generalizability of trial results. We assessed whether such a selection bias also exists in elderly patients with chronic angina referred for catheterization.. All 119 patients age>or=75 years with Trial of Invasive versus Medical Therapy in the Elderly (TIME) inclusion but no major exclusion criteria referred for catheterization during the TIME trial inclusion period in four TIME centers were registered and followed-up for one year. Registry patients differed from the 188 trial patients in the same hospitals in that they were younger, somewhat more frequently male, with less antianginal drugs and studied more often after acute chest pain at rest but with more comorbidities than study patients. Left ventricular ejection fraction and vessel disease were similar. One year mortality was 11.4% in registry and 9.6% in invasive TIME patients but differences disappeared after adjustment for baseline differences. Symptomatic status after one year was similar too.. In elderly patients with chronic angina, a bias in the selection for invasive management exists which seems different from that reported in younger patient settings. After adjustment for these selection factors, however, one-year outcome was remarkably similar in registry and trial patients.

Topics: Aged; Angina Pectoris; Cardiac Catheterization; Cardiovascular Agents; Chronic Disease; Coronary Angiography; Coronary Artery Disease; Female; Humans; Male; Myocardial Revascularization; Quality of Life; Risk Assessment; Selection Bias; Survival Rate; Treatment Outcome

To examine the epidemiology, primary care burden and treatment of angina in Scotland.. Cross-sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 2001 and 31 March 2002.. 55 primary care practices (362 155 patients).. 9508 patients with angina.. The prevalence of angina in Scotland was 28/1000 in men and 25/1000 in women (p < 0.05) and increased with age. The prevalence of angina also increased with increasing socioeconomic deprivation from 18/1000 in the least deprived category to 31/1000 in the most deprived group (p < 0.001 for trend). The incidence of angina was higher in men (1.8/1000) than in women (1.4/1000) (p = 0.004) and increased with increasing age and socioeconomic deprivation. Socioeconomically deprived patients (0.48 contacts/patient among the most deprived) were less likely than affluent patients (0.58 contacts/patient among the least deprived) to see their general practitioner on an ongoing basis p = 0.006 for trend). Among men, 52% were prescribed beta blockers, 44% calcium channel blockers, 72% aspirin, 54% statins and 36% angiotensin converting enzyme inhibitors or angiotensin receptor blockers. The corresponding prescription rates for women were 46% (p < 0.001), 41% (p = 0.02), 69% (p < 0.001), 45% (p < 0.001) and 30% (p < 0.001). Among patients < 75 years old 52% were prescribed a beta blocker and 58% a statin. The corresponding figures for patients >or= 75 years were 42% (p < 0.001) and 31% (p < 0.001).. Angina is a common condition, more so in men than in women. Socioeconomically deprived patients are more likely to have angina but are less likely to consult their general practitioner. Guideline-recommended treatments for angina are underused in women and older patients. These suboptimal practice patterns, which are worst in older women, are of particular concern, as in Scotland more women (and particularly older women) than men have angina.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Cost of Illness; Epidemiologic Methods; Female; Humans; Incidence; Male; Middle Aged; Patient Acceptance of Health Care; Prevalence; Scotland; Sex Distribution; Socioeconomic Factors

The prophylactic anti-anginal agent, perhexiline, may also be effective in acute coronary syndromes and advanced aortic valvular stenosis, conditions associated with enhanced inflammation. Its potential effects on superoxide formation via NADPH oxidase were measured by lucigenin-mediated chemiluminescence. Perhexiline inhibited superoxide formation in intact neutrophils stimulated with formyl Met Leu Phe (fMLP) 4 muM or with phorbol myristate acetate (PMA) 162 nM - IC50 2.3 microM (1.5-3.6), n=4. Sub-unit assembly of NADPH oxidase by PMA was unaffected by pretreatment with perhexiline 2 microM, a concentration which reduced superoxide formation by 44+/-5% (n=4) in intact neutrophils. Perhexiline inhibited preassembled neutrophil NADPH oxidase and that in membranes of pig valve interstitial cells, human umbilical vein endothelial cells (HUVECs) and cardiac fibroblasts, but not that in rat aorta (rings or membrane preparations). These data imply that perhexiline inhibits the phagocytic NADPH oxidase directly, and that pig aortic valvular interstitial cells possess a similar enzyme, a conclusion supported by immunohistochemical localisation of the gp91phox subunit in these cells. However further study is required to clarify the effect of perhexiline on different NADPH oxidase isoforms particularly in the vasculature.

Topics: Angina Pectoris; Animals; Animals, Newborn; Aorta, Thoracic; Aortic Valve; Cardiovascular Agents; Cell Membrane; Cells, Cultured; Dose-Response Relationship, Drug; Enzyme Inhibitors; Female; Free Radical Scavengers; Humans; In Vitro Techniques; Luminescent Measurements; Male; N-Formylmethionine Leucyl-Phenylalanine; NADP; NADPH Oxidases; Neutrophils; Perhexiline; Rats; Rats, Wistar; Superoxides; Swine; Tetradecanoylphorbol Acetate

Topics: Acetylcholine; Angina Pectoris; Bundle-Branch Block; Calcium Channel Blockers; Cardiovascular Agents; Coronary Vasospasm; Death, Sudden, Cardiac; Defibrillators, Implantable; Electrocardiography; Humans; Myocardial Ischemia; Syncope; Ventricular Fibrillation

Mildronate is a fatty acid oxidation inhibitor approved as an antianginal drug in parts of Europe. We carried out the first study to determine whether a 10-day course of mildronate could reduce myocardial infarct size (IS) during acute myocardial ischemia. Sprague Dawley rats received 200 mg/kg/d of mildronate (treated group, n = 16) or sterile water (control group, n = 14) subcutaneously for 10 days before ischemia-reperfusion. Rats were then subjected to 45 minutes of left coronary artery occlusion and 2 hours of reperfusion. The 2 groups had identical areas at risk: treated 38 +/- 3%; controls 38 +/- 2%. The amount of necrosis was smaller in the mildronate group at 16 +/- 2% of the left ventricle versus controls, 22 +/- 2% (P = 0.05); and for any amount of risk >25%, necrosis was smaller in the treated group (P = 0.0035). Myocardial IS (% of risk zone) was 43+/-3% in the mildronate-treated rats, and 57+/-4% in controls (P = 0.004). During occlusion, there were no differences between the 2 groups in heart rate (216 +/- 12 bpm, mildronate and 210 +/- 9 bpm, control), in mean arterial pressure (60 +/- 2 mm Hg, mildronate and 64 +/- 3 mm Hg, control) or in the frequency of arrhythmias. Our study for the first time demonstrated that a 10-day treatment with mildronate reduced myocardial IS in an experimental model of acute myocardial ischemia, without any effect on hemodynamics.

Topics: Angina Pectoris; Animals; Blood Pressure; Body Weight; Cardiovascular Agents; Fatty Acids; Female; Heart Rate; Methylhydrazines; Myocardial Infarction; Oxidation-Reduction; Rats; Rats, Sprague-Dawley

The purpose of this study was to evaluate predictors of an adverse outcome after "crush" bifurcation stenting.. The "crush" technique is a recently introduced strategy with limited data regarding long-term outcomes.. We identified 231 consecutive patients treated with drug-eluting stent implantation with the "crush" technique for 241 de novo bifurcation lesions. Clinical follow-up was obtained in 99.6%.. The in-hospital major adverse cardiac event (MACE) rate was 5.2%. At 9 months, 10 (4.3%) patients had an event consistent with possible post-procedural stent thrombosis. Survival free of target lesion revascularization (TLR) was 90.3%; the only independent predictor of TLR was left main stem (LMS) therapy (odds ratio [OR] 4.97; 95% confidence interval [CI] 2.00 to 12.37, p = 0.001). Survival free of MACE was 83.5% and independent predictors of MACE were LMS therapy (OR 3.79; 95% CI 1.76 to 8.14, p = 0.001) and treatment of patients with multivessel disease (OR 4.21; 95% CI 0.95 to 18.56, p = 0.058). Angiographic follow-up was obtained in 77% of lesions at 8.3 +/- 3.7 months. The mean late loss of the main vessel and side branch were 0.30 +/- 0.64 mm and 0.41 +/- 0.67 mm, respectively, with binary restenosis rates of 9.1% and 25.3%. Kissing balloon post-dilation significantly reduced the side branch late lumen loss (0.24 +/- 0.50 mm vs. 0.58 +/- 0.77 mm, p < 0.001).. The crush technique of bifurcation stenting with drug-eluting stents is associated with favorable outcomes for most lesions; however, efficacy appears significantly reduced in LMS bifurcations, and further research is needed before the technique can be routinely recommended in this group. Furthermore, the incidence of possible stent thrombosis is of concern and requires further investigation. Kissing balloon post-dilatation is mandatory to reduce side branch restenosis.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Coronary Thrombosis; Delayed-Action Preparations; Female; Humans; Male; Middle Aged; Paclitaxel; Postoperative Complications; Prognosis; Sirolimus; Stents; Time Factors; Treatment Outcome

Ivabradine is the first selective and specific inhibitor of the I(f) current (the cardiac pacemaker 'funny' current), and provides pure heart rate reduction without altering myocardial contractility, the cardiac conduction system or coronary vascular resistance. Clinical proof of the antianginal efficacy and tolerability of ivabradine comes from the largest clinical development programme that has ever been performed in stable angina, involving more than 5000 patients. Ivabradine was shown to be as effective as well-established reference antianginal drugs, such as beta-blockers and calcium antagonists. It is well tolerated and is free of the most commonly observed side effects of currently prescribed antianginal drugs. It offers clear therapeutic benefits for a whole range of patients with stable angina, including those with contraindications or intolerance to beta-blockers.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Animals; Benzazepines; Calcium Channel Blockers; Cardiovascular Agents; Drug Administration Schedule; Drug Evaluation, Preclinical; Drug Therapy, Combination; Heart Rate; Humans; Ivabradine; Myocardial Ischemia; Nitrates; Randomized Controlled Trials as Topic; Sinoatrial Node

Refractory angina pectoris is an exceptionally debilitating condition affecting patients who have typically failed multiple percutaneous and surgical revascularizations and optimal medical therapy and who are not amenable for further revascularization procedures. Spinal cord stimulation (SCS) has been adopted in this context at our institution and midterm mortality, anginal status, and quality of life have been evaluated.. From 1998 to 2004, 51 patients with refractory class III-IV angina, who were not considered candidates for revascularization procedures, underwent SCS. All patients had already undergone previous surgical revascularization and a median of two percutaneous procedures. Transmyocardial laser revascularization had been previously performed in 8 cases (15.6%). Most of the patients (70.5%) had experienced a myocardial infarction. Mean ejection fraction was 0.42 +/- 0.121, Canadian Cardiovascular Society class 3.5 +/- 0.5, quality of life (Spitzer index) 4.5 +/- 1.2, and the median frequency of weekly angina episodes was 10.. There were no SCS implantation-related complications. At follow-up (100% complete, mean 24 +/- 18 months), a significant improvement of anginal symptoms (>50% reduction of weekly anginal episodes) occurred in 45 patients (88.2%). In those patients (Responders), the quality of life improved significantly (6.8 +/- 1.5; p < 0.0001), CCS class decreased to 2 +/- 0.7 (p < 0.0001), and the median frequency of weekly angina episodes to 3 (p < 0.0001). At 3 years, Responders' survival was 91.8 +/- 4.6% and the freedom from cardiac events 72.6 +/- 8.42%.. Spinal cord stimulation is a safe and effective procedure in truly no-option patients affected by refractory angina. A midterm sustained improvement of symptoms and quality of life have been documented with a satisfactory 3-year survival rate.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Electric Stimulation Therapy; Electrodes, Implanted; Female; Humans; Male; Middle Aged; Prospective Studies; Quality of Life; Spinal Cord; Survival Analysis

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Clinical Trials as Topic; Europe; Humans; Myocardial Revascularization

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Humans; Placebo Effect; Treatment Outcome

In order to assess adherence to guidelines and international variability in management, the Euro Heart Survey of Newly Presenting Angina prospectively studied medical therapy, percutaneous coronary intervention (PCI), and surgery in patients with new-onset stable angina in Europe.. Consecutive patients, 3779 in total, with a clinical diagnosis of stable angina by a cardiologist were enrolled. After initial assessment by a cardiologist, 78% were treated with aspirin, 48% with a statin, and 67% with a beta-blocker. ACE-inhibitors were prescribed by the cardiologist in 37% overall. Revascularization rates were low, with only 501 (13%) patients having PCI or coronary bypass surgery performed or planned. However, when restricted to patients with coronary disease documented within 4 weeks of assessment, over 50% had revascularization performed or planned. Among other factors, the national rate of angiography and availability of invasive facilities significantly predicted the likelihood of revascularization, OR 2.4 and 2.0, respectively.. This survey shows a shortfall between guidelines and practice with regard to the use of evidence-based drug therapy and evidence that revascularization rates are strongly influenced by non-clinical, in addition to clinical, factors.

Topics: Analysis of Variance; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Decision Making; Europe; Female; Guideline Adherence; Hospitalization; Humans; Male; Middle Aged; Myocardial Ischemia; Myocardial Revascularization; Practice Guidelines as Topic; Prospective Studies; Referral and Consultation; Regression Analysis

Chronic angina is a common and disabling disorder in the elderly. Combined antianginal drug treatment represents the mainstay of therapy in this population. However, there is a paucity of data regarding the effect of this strategy on long-term outcome in the elderly.. To assess the long-term effect of combined antianginal drug therapy in elderly individuals, we performed a long-term follow-up analysis of all 148 patients of the Trial of Invasive versus Medical therapy in Elderly (TIME) patients with chronic symptomatic coronary-artery disease assigned to an optimized medical therapy strategy. Angina severity, measures of quality of life (QOL), and survival were assessed after a median of 3.7 (0.1-6.9) years.. At baseline, patients were 79.8 +/- 3.5 years old with Canadian Cardiovascular Society (CCS) class angina 3.0 +/- 0.7 despite the use of 2.4 +/- 0.6 antianginal drugs. Although antianginal drugs were increased to 2.8 +/- 0.9 (P < .01), 63 (43%) patients needed revascularization for refractory symptoms during the first year of observation (REVASC). At baseline, REVASC patients had more frequently CCS class 4 angina (37% vs 20%, P < 0.05) but reported less prior heart failure (5% vs 20%, P < 0.01), fewer prior cerebral events (3% vs 13%, P < .05) and a lower rate of two or more comorbidities (10% vs 33%, P < .01) than patients on continued drug therapy (DRUG). At long-term follow-up, angina severity was still higher in DRUG compared to REVASC patients (CCS class, 1.8 +/- 1.6 vs 1.0 +/- 1.4, P < .05) despite more antianginal drugs (2.1 +/- 1.1 vs 1.5 +/- 1.0, P < .01), whereas measures of QOL had improved similarly in both groups. In addition, long-term mortality was significantly higher in DRUG than in REVASC patients (38% vs 13%, P < .01).. Combined antianginal drug therapy successfully relieved symptoms in most elderly patients with chronic angina but failed to do so in 43%. Patients who needed revascularization for refractory symptoms reported less angina, despite lower drug use during long-term follow-up and had a better long-term survival. Thus, the widely used strategy to increase antianginal drug therapy in elderly patients instead of evaluating them for revascularization should be reconsidered.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Drug Administration Schedule; Drug Therapy, Combination; Female; Health Services for the Aged; Humans; Longitudinal Studies; Male; Myocardial Revascularization; Quality of Life; Randomized Controlled Trials as Topic; Severity of Illness Index; Survival Analysis; Switzerland

Reported here is an analytical method enabling the stereochemical resolution of a new antianginal compound possessing two stereogenic centers, leading to four stereoisomers. Only one of these isomers is currently under development as a novel antianginal agent and consequently, the other three isomers are considered as unwanted chiral impurities. Therefore, an enantioselective method is required in order to check its enantiomeric purity. This paper presents a method exploiting the high efficiency of capillary electrophoresis and the complexing properties of cyclodextrins to achieve the separation of the four stereoisomers of this weakly basic compound (pKa = 7.4). For this purpose, the combination of a neutral cyclodextrin, hydroxypropyl-gamma-cyclodextrin (HP-gamma-CD), and an anionic cyclodextrin, carboxymethyl-beta-cyclodextrin (CM-beta-CD), was added to the separation buffer running in an uncoated silica capillary. After selection of the suitable cyclodextrin system, satisfactorily separation conditions were as follows: 30 mM phosphate buffer (pH 6.4) containing 10 mM of HP-gamma-CD and 10 mM of CM-beta-CD, running voltage +30 kV. The resulting run time and resolutions were respectively about 17 min and between 1.95 and 2.84. Linearity curves (0.993 < r2 < 0.998) are also shown.

Topics: Angina Pectoris; beta-Cyclodextrins; Cardiovascular Agents; Electrophoresis, Capillary; gamma-Cyclodextrins; Humans; Molecular Structure; Reproducibility of Results; Stereoisomerism

The choice of optimal therapy in a patient with borderline coronary lesion is difficult. The long-term outcome of conservatively treated patients has not yet been well defined.. To analyse long-term outcome in patients with a borderline lesion in a single coronary artery who were selected for conservative treatment.. The study group consisted of 65 patients (mean age 59.4+/-7.4 years, 48 males) with (1) stable angina (CCS class I/II), (2) isolated single borderline coronary lesion (40-70% stenosis demonstrated by quantitative coronary angiography) and (3) no demonstrable ischaemia during non-invasive tests. Patients with heart failure, left ventricular ejection fraction <50% or acute coronary syndrome within 6 months preceding the study were not included. All patients were prescribed statins, angiotensin converting enzyme inhibitors and aspirin. Follow-up end-points included cardiac death, new myocardial infarction (MI) with or without ST segment elevation and revascularisation of the target coronary artery.. The follow-up duration was 18.4+/-8.5 months (range 12-33, median 18 months). Forty nine (75%) patients remained free from angina during daily activity. Coronary events occurred in 16 (25%) patients, including three (5%) serious complications -- sudden death, new MI with ST elevation and new MI without ST elevation. The remaining 13 (20%) patients underwent percutaneous revascularisation of the target coronary artery. Coronary angiography was repeated in 16 (25%) patients. When the patients were divided into two groups according to the follow-up results (with or without coronary event), no differences in the clinical characteristics, lesion localisation and length or degree of stenosis were noted.. (1) Conservatively treated patients with stable angina and borderline coronary stenosis have a high rate of coronary events, especially revascularisation, during a long-term follow-up. (2) Clinical parameters and quantitative coronary angiography do not identify those patients with borderline coronary lesions who are at increased risk of future coronary events.

Topics: Angina Pectoris; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Coronary Stenosis; Death, Sudden, Cardiac; Female; Heart Conduction System; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Time Factors; Treatment Outcome

Topics: Acetanilides; Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Drug Therapy, Combination; Humans; Myocardial Revascularization; Piperazines; Ranolazine; Risk

The social and economic burdens of chronic angina are enormous, and the morbidity and mortality associated with its underlying cause, coronary artery disease, are high. For many patients with chronic angina, current drug therapies are contraindicated or ineffective, and surgical procedures too risky or costly. Most newer approaches have not yet been sufficiently evaluated and can be expensive, time-consuming, or both. A new class of antianginal drugs, the metabolic modulators, will soon be available. In controlled clinical trials, these agents have shown promising results in reducing the frequency of angina episodes and lengthening the duration of exercise sessions. They are also well tolerated.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Humans; Metabolism; United States

Topics: Acetanilides; Angina Pectoris; Antihypertensive Agents; Cardiovascular Agents; Chronic Disease; Drug Interactions; Drug Therapy, Combination; Enzyme Inhibitors; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Piperazines; Ranolazine

Topics: Acetanilides; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Drug Therapy, Combination; Enzyme Inhibitors; Humans; Piperazines; Ranolazine

Although several studies describing the diagnostic and therapeutic management of patients with myocardial infarction (MI) by general practitioners have recently been published, little information exists about patients with angina without MI.. To describe the management of patients with angina without known MI in general practice.. A cross-sectional survey.. Italian general practitioners providing data to the Health Search Database.. Prevalent cases of angina, using the prescription of nitrates as a 'proxy' for disease status, in patients without known MI were selected from the Health Search Database. Data on patient demographics, clinical information, established therapies and cardiology visits were collected. A binomial logistic regression analysis was performed to test which variable made prescription more or less likely.. There were 10 455 patients with angina. Blood pressure readings were available for 73.8% of patients; in this group 58.9% had inadequate (> or = 140/90 mmHg) blood pressure control. Total cholesterol was recorded in 61.6% of cases (mean value = 5.5 mmol/L). Antiplatelet or oral anticoagulant agents were used by 67.8% of the patients, while 24.1% of patients received lipid-lowering agents, 61% received ACE-inhibitors or angiotensin-II receptor antagonists, and 25.2% received beta-blockers.. In patients treated with nitrates the monitoring of modifiable risk factors and the use of preventive drugs is lower than expected. New strategies aimed at improving secondary cardiovascular prevention among these easily identifiable high-risk subjects are needed.

Topics: Adolescent; Adult; Aged; Angina Pectoris; Cardiovascular Agents; Cross-Sectional Studies; Family Practice; Female; Humans; Italy; Male; Middle Aged; Nitrates; Regression Analysis; Retrospective Studies

To describe a single-center experience of using retrospectively gated multislice computed tomographic (MSCT) coronary angiography for imaging congenital coronary anomalies.. We retrospectively reviewed the clinical information and imaging studies for 9 patients diagnosed as having congenital coronary anomalies on invasive, selective coronary angiography between February 2001 and October 2003 at the Mayo Clinic in Jacksonville, Fla. Two experienced observers classified by consensus the origin and proximal course of the abnormal coronary arteries as seen on MSCT.. In 1 patient, MSCT showed a normal but extremely anterior origin of the right coronary artery from the right aortic sinus of Valsalva. In the other 8 patients, the origin and course of 4 anomalous right coronary arteries, 2 anomalous left circumflex coronary arteries, and 2 single coronary arteries were recognized easily on MSCT.. Similar to electron beam computed tomography and magnetic resonance imaging, widely available MSCT can characterize the proximal course of congenitally abnormal coronary arteries and thus aid in clinical decision making for patients with such anomalies.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Vessel Anomalies; Dyspnea; Female; Florida; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Observer Variation; Patient Selection; Predictive Value of Tests; Retrospective Studies; Tomography, Spiral Computed

Topics: Acetanilides; Adrenergic beta-Antagonists; Amlodipine; Angina Pectoris; Atenolol; Cardiovascular Agents; Chronic Disease; Diltiazem; Double-Blind Method; Exercise Test; Humans; Multicenter Studies as Topic; Piperazines; Placebos; Randomized Controlled Trials as Topic; Ranolazine; Time Factors; Vasodilator Agents

Topics: Acute Disease; Adrenergic beta-Antagonists; Angina Pectoris; Angina, Unstable; Anticoagulants; Cardiac Catheterization; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Electrocardiography; Fibrinolytic Agents; Humans; Myocardial Infarction; Nitrates; Platelet Aggregation Inhibitors; Platelet Glycoprotein GPIIb-IIIa Complex; Prognosis; Randomized Controlled Trials as Topic; Risk Factors; Syndrome; Thrombolytic Therapy; Time Factors

Topics: Aged; Angina Pectoris; Cardiac Catheterization; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Decision Making; Humans; Myocardial Revascularization; Prognosis

Effects of altiazem PP-180 ("Berlin Chemie", Germany; "Menarini Group". Italy) and dilren-300 ("Sanofi", France) on clinical symptoms and circadian hemodynamic chronostructure were studied in 22 patients with coronary heart disease (CHD) with stable angina pectoris of functional class II-III. Tetrapolar chest rheography (TCR), echocardiography (Echo-CG), ECG, arterial pressure measurement (APM) by N. S. Korotkov were used for examination. TCR, ECG and APM were made 6 times a day: at 10.00, 14.00, 18.00, 22.00, 02.00 and 06.00. The drugs were given in a single daily dose at 08.00 for 10 days. The information was processed statistically and by F. Halberg's cluster analysis. The results showed that altiazem PP and dilren had an antianginal activity which is stronger in dilren administration. The drugs produced moderate hypotensive and vasodilating effects. Altiazem PP raised mean daily level of stroke and minute volumes and their indices. Dilren raised ejection fraction and reduced the double product. Dilren normalized chronostructure of hemodynamic circadian rhythms.

Topics: Adult; Aged; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Chronotherapy; Circadian Rhythm; Cluster Analysis; Coronary Disease; Diltiazem; Female; Hemodynamics; Humans; Male; Middle Aged; Stroke Volume; Time Factors; Vasodilator Agents

Topics: Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Coronary Angiography; Electrocardiography; Fibrinolytic Agents; Humans; Myocardial Infarction; Myocardial Revascularization; Prognosis; Time Factors; Treatment Outcome

Topics: Anesthesia, Dental; Angina Pectoris; Arrhythmias, Cardiac; Cardiovascular Agents; Cardiovascular Diseases; Dental Care for Chronically Ill; Endocarditis, Bacterial; Humans; Medical History Taking; Physical Examination; Risk Factors; Vasodilator Agents

This audit aimed to assess the identification and treatment of coronary risk factors, lifestyle advice given and use of drug therapy, among patients with angina in Sandwell. It was designed to help general practices evaluate their angina management, and highlight areas where practice could be improved. Criteria were based on Sandwell's published angina audit and local clinical guidelines. Each participating practice was asked to identify all patients with angina, from which a 10% sample was randomly selected. The notes of each selected patient were examined for evidence showing whether agreed standards of care had been achieved. Fifteen practices took part, and contributed data on a total of 358 patients. Of patients without contraindications, 66.5% were taking aspirin, 62.1% were prescribed short-acting nitrates and 58.4% were prescribed beta-blockers. Non-white patients were significantly less likely to receive short-acting nitrates (p < 0.001) and women were significantly less likely to receive beta-blockers (p < 0.01). A total of 83.5% of patients had received smoking cessation advice, 75.1% had weight advice, 75.1% were advised about alcohol use and 64.5% about exercise. Overall, 77.4% had a blood pressure check within the previous twelve months, 40.5% had their cholesterol measured and 33.5% had their blood glucose measured. Non-white patients were significantly less likely to receive smoking cessation, weight, exercise and alcohol advice and were less likely to have their blood pressure checked (all p < 0.0001). Patients aged 65 and over were significantly less likely to receive a cholesterol check (p < 0.0001). None of the auditable standards were actually met. This study shows that there is considerable scope to improve the management of angina patients, with particular regard to aspirin. We recommend that practices develop systems to ensure that the appropriate treatment, advice and checks are given to all patients with angina, paying particular attention to those from ethnic minority backgrounds.

Topics: Angina Pectoris; Blood Glucose; Blood Pressure Determination; Cardiovascular Agents; Cholesterol; Counseling; Drug Prescriptions; Drug Utilization; England; Female; Health Services Accessibility; Humans; Life Style; Male; Medical Audit; Patient Care Management; Patient Education as Topic; Practice Guidelines as Topic; Practice Patterns, Physicians'; Primary Health Care

1) To develop an estimate of oral clearance (CL(Px)/F) for the antianginal agent perhexiline based on the ratio of cis-OH-perhexiline metabolite/parent perhexiline plasma concentrations at steady-state (C(OHPx,ss)/C(Px,ss)). 2) To determine whether the ratio measured in the first fortnight of treatment (C(i)(OHPx)/C(i)(Px)) may be used to guide patient dosing with perhexiline, a drug with a narrow therapeutic index, long half-life and saturable metabolism via CYP2D6.. Two retrospective studies were conducted reviewing patient records and data obtained from routine monitoring of plasma perhexiline and cis-OH-perhexiline concentrations.. Study 1 (n=70). At steady-state, the frequency distributions of CL(Px)/F and C(OHPx,ss)/C(Px,ss) were consistent with CYP2D6 metabolism. Putative poor metabolizers (approximately 8%) were identified by CL(Px)/F< or =50 ml min(-1) or C(OHPx,ss)/C(Px,ss)< or =0.3. A group of patients with CL(Px)/F> or =950 ml min(-1) may have been ultra-rapid metabolizers. In this group, the high CL(Px)/F values suggest extensive first-pass metabolism and poor bioavailability. In patients with therapeutic plasma perhexiline concentrations (0.15-0.60 mg l(-1)), the variability in dose appeared directly proportional to CL(Px)/F (r2=0.741, P<0.0001). Study 2 (n=23). Using C(i)(OHPx)/C(i)(Px) patients were tentatively identified as poor, extensive and ultra-rapid metabolizers, with CL(Px)/F of 23-72, 134-868 and 947-1462 ml min(-1), respectively, requiring doses of 10-25, 100-250 and 300-500 mg day(-1), respectively.. The cis-OH-perhexiline/perhexiline concentration ratio may be useful for optimizing individual patient treatment with the antianginal agent perhexiline.

Topics: Angina Pectoris; Biological Availability; Cardiovascular Agents; Chromatography, High Pressure Liquid; Cytochrome P-450 CYP2D6; Humans; Metabolic Clearance Rate; Perhexiline; Phenotype; Retrospective Studies; Sensitivity and Specificity

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Humans; Randomized Controlled Trials as Topic; Survival Rate; Treatment Outcome

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Disease; Humans; Quality of Life; Risk; Survival Rate

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Heart Diseases; Humans

Topics: Aged; Angina Pectoris; Angioplasty; Attitude to Health; Cardiovascular Agents; Coronary Artery Bypass; Female; Humans; Male; Quality of Life

Ischaemic heart disease is a leading cause of death in the world. It has clinically defined phases as: Asymptomatic, stable angina, progressive angina and unstable angina. It is important to differentiate patients of angina into those with stable and unstable angina--risk stratification and management differ in the two groups. Risk stratification of patients with stable angina using clinical parameters helps in development of clearer indication of referral for exercise testing and cardiac catheterisation. Chronic stable angina patients with history of documented myocardial infarction of Q waves on ECG should have measurement of left ventricular systolic function (ie, ejection fraction) as it is important for choosing the appropriate medical or surgical therapy. Symptomatic patients with suspected or known coronary artery disease should usually undergo exercise testing to assess the risk of future cardiac events. The treatment of stable angina has two purposes: To prevent myocardial infarction and death and therapy directed towards preventing death. Pharmacotherapy consists of: Aspirin, lipid lowering agents, beta-blockers, nitrates, short acting dihydropyridine calcium antagonists, etc. For surgery, there are two well established approaches of revascularisation. One is coronary artery by-pass grafting and the other is percutaneous transluminal coronary angioplasty. Studies comparing different treatment modalities are elaborated in this article. In conclusion, it can be said that patients having severe symptoms affecting quality of life despite optimal medical therapy should be referred for revascularisation surgery.

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Electrocardiography; Exercise Test; Humans; India; Myocardial Infarction; Myocardial Revascularization; Recurrence; Risk Factors; Survival Rate

Nitrates are one of the most commonly prescribed drug groups for cardiac disease, especially for angina pectoris and congestive heart failure. The chronic efficacy of nitrates is limited by the development of tolerance, which can be attenuated by use of sustained-release preparations or administration of regular-release preparations asymmetrically.. To determine whether patients receiving isosorbide 5-mononitrate (ISMN) use the drug in a pharmacologically appropriate manner and whether they had been instructed in the prophylactic use of sublingual nitrates prior to effort.. We administered a questionnaire regarding details of nitrate use to 229 patients with ischemic heart disease using oral ISMN, prescribed prior to their current admission. The study was conducted in a 600-bed university-affiliated hospital.. We found that only 15% of patients receiving regular-release ISMN were taking the drug asymmetrically. In contrast, 82.6% of the patients receiving sustained-release ISMN were using the drug properly. Only 38.1% of the patients treated with regular-release ISMN were treated with the dose recommended in the literature. Furthermore, of the 190 patients who reported experiencing effort angina, only 17.9% had been instructed in the prophylactic use of nitrates prior to effort.. The majority of patients (85%) using regular-release ISMN were taking the medication in an inappropriate fashion, while most patients taking sustained-release preparations were using them properly. More than half the patients treated with regular-release ISMN were treated with doses exceeding the recommended dose. In addition, most patients experiencing effort angina had not been instructed regarding the prophylactic use of nitrates. These findings suggest that both physicians and pharmacists must be reminded of the continuing need to properly counsel patients regarding appropriate drug use.

Topics: Administration, Sublingual; Aged; Angina Pectoris; Cardiovascular Agents; Drug Prescriptions; Drug Utilization Review; Female; Humans; Male; Middle Aged; Myocardial Ischemia; Nitrates; Surveys and Questionnaires

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Coronary Vessels; Female; Humans; Male; Randomized Controlled Trials as Topic; Reproducibility of Results; Treatment Outcome

Angina pectoris is a common medical problem in the community requiring a multifaceted approach to treatment in order to improve the quality of life and long term prognosis for the patient.. To discuss some of the practical aspects of the medical management of patients with stable angina pectoris, including anti ischaemic medications and secondary prevention strategies.. Decreasing the risk of rapid progression of atherosclerosis in patients with angina is probably the most important factor in long term management. Also, careful use of anti ischaemic and anti platelet medications may prevent further serious cardiac events and improve quality of life.

Topics: Aged; Angina Pectoris; Arteriosclerosis; Cardiovascular Agents; Diagnosis, Differential; Female; Humans; Male; Middle Aged; Myocardial Revascularization; Quality of Life; Risk Factors

Topics: Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Diltiazem; Drug Overdose; Humans; Male; Middle Aged

Long-term nitrate therapy for ischemic heart disease may cause drug tolerance which diminishes its beneficial effects; consequently, intermittent administration of nitrates is recommended. With this regimen, however, the potential occurrence of rebound angina during the nitrate-free intervals is a source of concern.. We carried out a retrospective study of 606 patients to determine whether rebound angina occurred when conventional continuous nitrate administration was replaced by intermittent administration as part of a long-term therapy protocol for prior myocardial infarction. The subjects were receiving treatment for myocardial infarction and included 293 patients treated with nitrates (Nitrate group) and 313 patients who were not (No-nitrate group). The former included 186 patients who received intermittent nitrate administration (Intermittent group) and 107 patients who received continuous administration (Continuous group). The mean period of observation was 4.3 +/- 1.6 months.. There were no cases of rebound angina in the Intermittent group. Cardiac events occurred in one case in the No-nitrate group (0.3%), in 4 cases in the Continuous group (3.7%) and in 2 cases in the Intermittent group (1.1%). The incidence of cardiac events was thus significantly increased in the Continuous group compared to the No-nitrate group (p < 0.05; odds ratio 9.06; 95% CI 1.41-58.28). The Intermittent group did not significantly differ from the No-nitrate group in the incidence of cardiac events.. It is concluded that intermittent administration of nitrates does not cause rebound angina and is therefore safe. A randomized controlled trial is needed to find the long-term effect on cardiac events.

Topics: Administration, Cutaneous; Administration, Oral; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Vasospasm; Delayed-Action Preparations; Disease-Free Survival; Drug Administration Schedule; Drug Therapy, Combination; Drug Tolerance; Exercise Tolerance; Female; Follow-Up Studies; Heart Failure; Humans; Isosorbide Dinitrate; Male; Middle Aged; Myocardial Infarction; Nitroglycerin; Recurrence; Retrospective Studies; Treatment Outcome

To examine discrepancies between co-morbidity of patients included in pre-marketing clinical trials of cardiovascular drugs and patients from daily practice, representing the actual users after marketing, and to investigate the availability of data regarding co-morbidity in registration files.. Data were collected from phase III trials of registration files of 16 drugs, registered in the Netherlands in the period 1985 through 1994 for the indications hypertension, angina pectoris or hypercholesterolemia, and from a general practitioners database. Patients were selected who used drugs from the same therapeutic classes for the same indication as the patients in the pre-marketing trials. Prevalences of concomitant cardiovascular, endocrine and metabolic diseases were compared between pre- and postmarketing populations. Discrepancies were defined as more than 10% difference in prevalences.. Data regarding co-morbidity were present in 13 out of 16 registration files and differed in format of reporting. For all indications, coexisting cardiovascular, endocrine and metabolic diseases were less prevalent in the pre-marketing populations, except ischemic heart disease, which was more prevalent coexisting with angina pectoris and hypercholesterolemia. Discrepancies were found for hypertensive disease, heart failure, diabetes mellitus and myocardial infarction.. Phase III trials testing cardiovascular drugs included patients with concomitant cardiovascular, endocrine and metabolic diseases, but discrepancies were present with patients in daily practice. Development of guidelines for uniform collection and reporting of co-morbidity data in pre-marketing trials is recommended, as well as further utilization of data.

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Trials, Phase III as Topic; Comorbidity; Databases, Factual; Family Practice; Humans; Hypercholesterolemia; Hypertension; Metabolic Diseases; Netherlands; Patient Selection; Pharmacoepidemiology; Prevalence; Registries

Percutaneous coronary revascularization frequently relieves angina in patients with ischemic heart disease and may obviate the need for antianginal medications.. To examine the use of antianginal medications after successful percutaneous coronary revascularization.. Retrospective cohort study of the Mayo Clinic PTCA [percutaneous transluminal coronary angioplasty] Registry.. Tertiary care center.. 3831 patients who underwent successful percutaneous coronary revascularization from September 1979 through August 1997 and had not had myocardial infarction within the year before the intervention.. Use of antianginal medications (beta-adrenergic blockers, nitrates, and calcium-channel blockers) before the intervention, at hospital discharge, and 6 months after the intervention.. 99% of patients reported improvement in their symptoms at hospital discharge. At 6 months, 87% of patients were free of myocardial infarction, coronary bypass surgery, or additional percutaneous intervention. Compared with 66% of patients before the index intervention, only 12% of patients had severe angina at 6 months and 69% were completely free of angina. Nonetheless, at 6 months, 39% of patients were receiving beta-adrenergic blockers (preprocedure proportion, 43%; P < 0.001), 36% were receiving nitrates (preprocedure proportion, 41%; P < 0.001), and 57% were receiving calcium-channel blockers (preprocedure proportion, 50%; P < 0.001). These trends persisted for patients without hypertension and those who had complete revascularization.. Successful percutaneous coronary revascularization did not substantially supplant the use of antianginal medications, which were commonly used despite the marked improvement in anginal status. This may reflect reluctance to alter therapy once symptoms of angina subside. Guidelines on continued medical therapy after percutaneous coronary revascularization are needed.

Topics: Adrenergic beta-Antagonists; Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Female; Follow-Up Studies; Humans; Male; Middle Aged; Nitrates; Postoperative Period; Retrospective Studies

To describe variations by age, sex, symptom severity and hospital region in the use of various medications amongst patients with stable angina pectoris who are candidates for coronary revascularization.. Patients (n = 2030) with chronic stable angina pectoris participating in a national survey evaluating the appropriateness of the use of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG).. As part of a national study of the appropriateness of coronary revascularization, data were prospectively collected on patients referred for consideration of coronary revascularization to seven of the eight public Swedish heart centres that performed approximately 92% of all bypass operations in Sweden in 1994.. Amongst all patients 76% were treated with beta blockers, 41% with calcium antagonists and 71% with long-acting nitrates and 70% were treated with at least two of these three drugs. Eighty-two per cent of the patients used aspirin and 14% lipid-lowering drugs. According to logistic regression analysis, with medication as the dependent variable and independent variables of age, sex, angina functional class, findings at exercise test, history of various diseases and region in Sweden where the investigation took place, the most consistent factor explaining the use of various medications was found to be geographical region. A previous history of acute myocardial infarction (AMI) was also associated with the use of all drugs and age was associated with all with the exception of beta blockers. Sex was not an independent factor explaining the use of any of the drugs.. In a national survey including patients with stable angina pectoris who are potential candidates for coronary revascularization, the most important predictor for the use of various medications was the geographical region in which the investigation took place.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Humans; Hypolipidemic Agents; Male; Middle Aged; Prospective Studies; Severity of Illness Index; Sex Factors; Sweden

The CD40 ligand (CD40L) on activated T cells and platelets may be activating matrix metalloproteinases, inducing procoagulant activity, and be involved in the pathogenesis of acute coronary syndromes by promoting plaque rupture in atheroma.. To study the role of CD40L-CD40 interaction in coronary disease, we analyzed levels of soluble (s) and membrane-bound CD40L in the peripheral blood from 29 patients with stable angina, 26 with unstable angina, and 19 controls. Our main findings follow. (1) Patients with unstable angina had significantly raised serum levels of sCD40L when compared with patients with stable angina and controls. (2) Platelets could release large amounts of sCD40L when stimulated ex vivo with the thrombin receptor-agonist peptide SFLLRN in both patients and controls. (3) Platelets in patients with unstable angina were characterized ex vivo by decreased intracellular levels and decreased SFLLRN-stimulated release of sCD40L, which may possibly represent a higher percentage of degranulated platelets in these patients. (4) T cells in patients with unstable angina had enhanced surface expression of CD40L and increased release of sCD40L on anti-CD3/anti-CD28 stimulation in vitro when compared with patients with stable angina and controls. (5) Recombinant CD40L and serum from patients with unstable angina who had high sCD40L levels induced enhanced release of monocyte chemoattractant peptide-1 from mononuclear cells, a CC-chemokine involved in the pathogenesis of atherosclerosis.. This first demonstration of enhanced levels of soluble and membrane-bound forms of CD40L in angina patients, with particularly high levels in patients with unstable angina, suggests that CD40L-CD40 interaction may play a pathogenic role in both the long-term atherosclerotic process and in the triggering and propagation of acute coronary syndromes.

Topics: Acute Disease; Aged; Angina Pectoris; Angina, Unstable; Blood Platelets; Cardiovascular Agents; CD4-Positive T-Lymphocytes; CD40 Antigens; CD40 Ligand; CD8-Positive T-Lymphocytes; Cell Membrane; Chemokine CCL2; Cholesterol; Coronary Disease; Cytoplasmic Granules; Female; Humans; Male; Membrane Glycoproteins; Metalloendopeptidases; Middle Aged; Peptide Fragments; Platelet Activation; Rupture, Spontaneous; Smoking; Solubility; Syndrome; Triglycerides; Vasculitis

Perhexiline is a prophylactic antianginal agent particularly useful in patients whose angina is poorly controlled or refractory to conventional drug regimens. Although perhexiline can cause serious hepatic and neurological toxicity, maintaining trough plasma concentrations between 0.15-0.60 mg/L minimizes the risk of toxicity while providing relief of angina symptoms in a majority of patients. All pathology laboratories are required to participate in interlaboratory proficiency testing (PT) programs. The authors therefore initiated a monthly PT program to assess the performance of Australian laboratories measuring perhexiline (n = 8). PT specimens included perhexiline-spiked drug-free human plasma and pooled plasma from patients administered perhexiline. The performance of 8 Australian laboratories participating in the program was examined over a 30-month period. The mean relative standard deviation of the group was 18.2%. All centers performed well with respect to accuracy, achieving mean percentage bias within +/-8% of target perhexiline concentrations. The usefulness of the PT program was highlighted by the identification of two laboratories with an unacceptable degree of variability (up to 30% of results varied more than +/-55% from the target concentration), and the identification of potential analytical problems with the use of perhexiline metabolite concentrations for determining patients' hydroxylator status. Continued and improved use of PT by pathology laboratories is essential to ensuring the safe and effective clinical use of perhexiline.

Topics: Angina Pectoris; Australia; Cardiovascular Agents; Chromatography, Gas; Chromatography, High Pressure Liquid; Drug Monitoring; Humans; Laboratories; Perhexiline; Quality Control; Reproducibility of Results

Topics: American Heart Association; Angina Pectoris; Association; Cardiovascular Agents; Humans; Practice Guidelines as Topic

A circadian variation has been observed for acute coronary syndromes (myocardial infarction, sudden cardiac death, angina pectoris) with a peak during the morning and a trough during the night. The previous reports, however, were based primarily on selected patients in clinical studies. The present study has been designed to determine the timing of attacks of angina pectoris in ambulatory patients, the association of wake time and possible external triggers with angina attacks, and the influence of cardiac medication. The European Survey on Circadian Variation of Angina Pectoris is a multicenter international cross-sectional survey of outpatients treated in general medical practice of seven European countries. Inclusion criteria are stable angina pectoris for at least 3 months, average frequency of two or more attacks per week, and treatment with on-demand nitrates. Standardised self-administered questionnaires are provided to all consecutive patients and their physicians. From January to July 1998, 1087 patients (61% male, 64 +/- 9 years; 39% female, 67 +/- 10 years) were enrolled in 196 centers. A total of 3453 angina pectoris attacks were reported, on average 3.2 per patient per week (range 0-48). The occurrence of angina pectoris attacks demonstrates a significant circadian variation (p < 0.001) with a primary morning peak from 9:00 to 12:00 (relative risk 3.0 compared with other times of day) and a secondary afternoon peak from 15:00 to 18:00. Of all attacks, 50% occured within 6 h after awakening. Seventy-four percent of all patients reported possible external triggers of angina such as physical activity or anger. The present multicenter survey in general medical practice demonstrates a marked wake time related circadian variation in angina pectoris attacks. To improve preventive strategies, therefore, type, dosage and particularly timing of cardiac medication appear of importance, as may be behavior modification approaches.

Topics: Aged; Ambulatory Care; Angina Pectoris; Cardiovascular Agents; Circadian Rhythm; Cross-Sectional Studies; Data Collection; Europe; Female; Humans; Male; Middle Aged

Topics: Angina Pectoris; Cardiovascular Agents; Cytoprotection; Humans; Myocardium

We characterized a contemporary, nonhospitalized population with angina pectoris by obtaining data from a geographically diverse cohort of 5125 outpatients with chronic stable angina cared for by 1266 primary-care physicians. Diagnosis was based on history supported by evidence for coronary artery disease (coronary angiography, old myocardial infarction [MI], and/or an abnormal stress test). Their mean age was 69 years and 53% were women. Seventy percent had more than one associated illness, and 65% used more than one cardiovascular drug. Calcium antagonists (46%) and nitrates (61%) were used most frequently. Median angina frequency was approximately 2 episodes/week, and increased angina frequency was associated (P < 0.0001) with decreased overall feeling of well-being. Although effort angina was present in 90% of patients, 47% also had rest angina and 34% had mental stress-evoked angina. Female gender (odds ratio: 1.09; 95% CI: 1.02-1.16), concomitant illness (1.17, 1.09-1.25), and pharmacotherapy (1.14, 1.07-1.22) were associated with rest angina. Younger age (1.30, 1.20-1.41), female gender (1.16, 1.07-1.26), concomitant illness (1.13, 1.03-1.24), and pharmacotherapy (1.28, 1.15-1.93) were associated with mental stress angina. Calcium antagonists were used for rest-evoked (1.09, 1.03-1.16) and mental stress-evoked (1.12, 1.04-1.21) angina. These data suggest that contemporary outpatients with angina are most likely to be women and elderly patients with high frequencies of associated illness, calcium antagonist and nitrate use, as well as rest- and mental stress-related angina. These characteristics differ from previous perceptions.

Topics: Age Distribution; Aged; Angina Pectoris; Cardiovascular Agents; Cohort Studies; Comorbidity; Female; Florida; Health Status; Humans; Male; Middle Aged; Prevalence; Quality-Adjusted Life Years; Sex Factors; Surveys and Questionnaires

Topics: Aged; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Chronic Disease; Delayed-Action Preparations; Diltiazem; Drug Evaluation; Female; Hemodynamics; Humans; Male; Middle Aged; Myocardial Ischemia; Physical Exertion; Time Factors

Symptoms of chronic stable angina are easily identifiable and indicate that a patient is at increased risk of heart attack and death. In patients with less severe angina, medical treatments are as effective as more invasive treatments and produce better survival rates. There is little evidence that the main types of medical treatment differ in effectiveness. For patients at higher risk, invasive revascularisation procedures--coronary artery bypass grafting (CABG) and angioplasty--are more appropriate. CABG is slightly more effective than angioplasty. A high proportion of patients receiving angioplasty require re-treatment. The risk of recurrence and coronary events is reduced if patients who receive invasive procedures also have long-term low dose aspirin and cholesterol-lowering therapy. There is no clear evidence that intracoronary stents are more cost-effective than standard angioplasty. There is a need for evidence-based guidance to help determine referral thresholds for further investigation, and revascularisation procedures. There is evidence of inequality of access to testing and treatment, by gender, ethnic group and social class. Access should be monitored in order to promote equity.

Topics: Angina Pectoris; Angioplasty, Balloon; Aspirin; Cardiovascular Agents; Coronary Artery Bypass; Evidence-Based Medicine; Hospital Mortality; Hospitals, Public; Humans; Management Audit; Myocardial Infarction; State Medicine; United Kingdom

This study was designed to examine the plasma levels of B-type or brain natriuretic peptide (BNP), as well as A-type or atrial natriuretic peptide (ANP) in patients with unstable angina as compared with those in patients with stable exertional angina and control subjects. We measured the plasma levels of BNP and ANP in 33 patients with unstable angina, 20 patients with stable exertional angina, and 20 control subjects. The plasma levels of BNP were significantly increased in patients with unstable angina compared with those in patients with stable exertional angina and control subjects, respectively (39.5 +/- 29.4 pg/ml vs 15.1 +/- 8.0 pg/ml; p < 0.01 and 39.5 +/- 29.4 pg/ml vs 10.3 +/- 6.4 pg/ml; p < 0.01, respectively). On the other hand, there was no significant difference in the plasma levels of ANP among the three groups. Furthermore, in patients with unstable angina, the plasma levels of BNP decreased significantly after the medical treatment (from 39.5 +/- 29.4 pg/ml to 15.8 +/- 11.0 pg/ ml; p < 0.01), whereas the plasma levels of ANP did not change. We conclude that the plasma levels of BNP are increased in the majority of patients with unstable angina and that the increased levels decrease toward normal after treatment.

Topics: Adult; Aged; Angina Pectoris; Angina, Unstable; Atrial Natriuretic Factor; Cardiovascular Agents; Echocardiography; Electrocardiography; Electrocardiography, Ambulatory; Female; Humans; Male; Middle Aged; Myocardial Ischemia; Natriuretic Peptide, Brain; Nerve Tissue Proteins; Physical Exertion

Topics: Adenosine; Angina Pectoris; Cardiovascular Agents; Exercise Test; Humans; Male; Middle Aged; Tachycardia, Sinoatrial Nodal Reentry

Topics: Aged; Angina Pectoris; Biological Availability; Cardiovascular Agents; Drug Compounding; Female; Humans; Male; Middle Aged; Perhexiline; Therapeutic Equivalency

When no anaesthetic is used, even 3-5 short-term disturbances of the myocardium supply with blood (during a few days) are enough for its initial necrosis and for damage of its vascular bed. In acute experiments on rats rutin discovers the ability to resist such damages, but on the chronic model of stenocardia in dogs its therapeutic effect can be found only under conditions of limitation of the ischemic effect by purposefully chosen complex medicinal therapy.

Topics: Anesthesia; Angina Pectoris; Animals; Cardiovascular Agents; Coronary Vessels; Disease Models, Animal; Dogs; Drug Evaluation, Preclinical; Heart; Myocardial Ischemia; Myocardium; Necrosis; Rats; Rutin; Time Factors

Topics: Angina Pectoris; Cardiovascular Agents; Clinical Trials as Topic; Drug Design; Heart Failure; Humans; Myocardial Contraction

Hemosorption and plasmapheresis were studied for effects on lipid peroxidation, antioxidant blood activity, platelet hemostasis, microcirculation, myocardial contractility and intracardiac hemodynamics. The results demonstrated that antioxidant blood response is a key criterion responsible for decreased efficacy of hemosorption and plasmapheresis in patients with progressive angina pectoris with chronic heart failure. The results of hemosorption and plasmapheresis in the above patients may become better if an adjuvant antioxidant therapy is used.

Topics: Angina Pectoris; Cardiovascular Agents; Chronic Disease; Combined Modality Therapy; Drug Therapy, Combination; Evaluation Studies as Topic; Female; Heart Failure; Hemoperfusion; Humans; Male; Myocardial Ischemia; Physical Exertion; Plasmapheresis

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Artery Disease; Coronary Disease; Drug Evaluation; Humans; Myocardial Ischemia

Topics: Angina Pectoris; Australia; Cardiovascular Agents; Dose-Response Relationship, Drug; Drug Administration Schedule; Humans

By the results of bicycle ergometry test 28 coronary heart disease (CHD) patients were divided into 2 groups: with a pronounced anginal syndrome (group 1) and coronary insufficiency evident on ECG (group 2). Vegetative and psychophysiological parameters obtained in the examinees (heart rate, arterial pressure, pain threshold, personality profile) demonstrated that increased pain sensitivity, anxiety, predisposition to neurotic reactions were more typical for patients of group 1. Therapeutic response was achieved after psychophysiological correction by means of creation and activation of artificial stable functional connections of the brain.

Topics: Adult; Aged; Angina Pectoris; Blood Pressure; Cardiovascular Agents; Diazepam; Drug Therapy, Combination; Electrocardiography; Etimizol; Exercise Test; Female; Heart Rate; Humans; Male; Middle Aged; Myocardial Ischemia; Photic Stimulation; Psychophysiology

Prevalence of type 1 silent myocardial ischemia (SMI; completely asymptomatic patients) is reported to appear 2 to 4% of the general population. The prognosis of these patients is said to be similar to that of patients with angina pectoris. Our study investigated a 10-year follow up of silent myocardial ischemia detected by bicycle exercise testing in comparison to a comparable control group. 10 years later 127 patients were reinvestigated by bicycle ergometry, 33 patients out of the SMI-group (group A) and 84 patients out of the control group (group B). Mean age in group A was 62 +/- 7 years (range 42 to 71 years), in group B 56 +/- 7 years (range 29 to 69 years). After 10 years there was no statistical significant difference between the 2 groups on using beta-blockers, calciumchannel-blockers and nitrates, on arterial hypertension, diabetes mellitus, smoking history and positive family-history as well as in total cholesterol, HDL- and LDL-cholesterol, triglycerides, blood glucose and uric acid. 1 patient of A and 2 of B died from a sudden cardiac death, 2 of A and 7 of B survived a myocardial infarction, 11 of A and 11 of B developed angina pectoris (p < 0.05). A statistical significant difference was found in the ergometric working capacity (maximal workload in Watt) between the 2 groups (p < 0.001) that did not change over the 10 years, the control group worked better in both investigations. SMI type 1, detected by bicycle ergometry seems to be only a risk factor for developing "loud ischemia" (= angina pectoris) but not for "hard events". A routine screening of completely asymptomatic persons with bicycle ergometry seems to have no prognostic relevance.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Cause of Death; Exercise Test; Female; Follow-Up Studies; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Ischemia; Survival Rate

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Arrhythmias, Cardiac; Aspirin; Cardiovascular Agents; Heart Failure; Humans; Myocardial Infarction; Platelet Aggregation Inhibitors

The sympathetic-adrenal and kallikrein-kinin systems were studied in 225 patients with various coronary heart diseases before and after therapy with lipoic acid (150 mg/day), tocopherol (100 mg/day), anaprilin (40 mg/day), prodectin (750 mg/day) or their combination. Myocardial and adrenal catecholamine levels were measured in experiments on animals exposed to emotional pain stress. Their levels were found to be affected by lipoic acid, tocopherol, obsidan or their combinations in the same doses, taking into account species specificity. Lipoic acid therapy for patients with coronary heart disease decreased epinephrine excretion, enhanced the elimination of vanillylmandelic acid and norepinephrine. Tocopherol lowered daily urinary epinephrine levels and increased the release of vanillylmandelic acid, without changing epinephrine excretion. Emotional pain stress resulted in myocardial epinephrine accumulation and adrenal norepinephrine in the animals. Lipoic acid prevented this accumulation, whereas tocopherol did not possess this effect.

Topics: Adolescent; Adrenal Glands; Adult; Aged; Angina Pectoris; Animals; Cardiovascular Agents; Drug Evaluation; Drug Evaluation, Preclinical; Drug Therapy, Combination; Humans; Kallikrein-Kinin System; Male; Middle Aged; Myocardial Ischemia; Neurotransmitter Agents; Pain; Rats; Stress, Psychological; Sympathetic Nervous System

Twenty-two patients with coronary heart disease (CHD) were examined for pain threshold and pain tolerance by a tourniquet test. The relationships between pain and ST segment depression were studied simultaneously during bicycle exercise. Pain sensitivity was measured in response to action of various antianginal drugs (isosorbide dinitrate, verapamil, nifedipine, diltiazem, propranolol, atenolol) and placebo. Reproducibility of the tourniquet test proved satisfactory. There were significant correlations between tourniquet test evidence and clinical patterns of ischemic myocardial episodes: significant differences in the values of pain threshold and pain tolerance in patients with painful myocardial ischemia, in combination of angina of effort with painless myocardial ischemia (p < 0.0001). Significant were also correlations between tourniquet test findings at bicycle exercise and value describing the proportion of ST depression to pain. As for the drugs, verapamil appeared most active in the tourniquet test (p < 0.02 and p < 0.05 for pain threshold and pain tolerance, respectively). Pain tolerance changes due to isosorbide dinitrate were somewhat greater than for placebo (p = 0.06). The study provided evidence in support of the adequacy of the tourniquet test for assessment of general pain sensitivity and pain sensitivity to myocardial ischemia as well as of analgetic effects of the drugs. Verapamil and isosorbide dinitrate are suggested to have analgetic activity.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Drug Evaluation; Exercise Test; Humans; Least-Squares Analysis; Male; Middle Aged; Myocardial Ischemia; Pain Measurement; Pain Threshold; Tourniquets

A single administration of nitroglycerin, corinfar, anapriline was studied for effects on exercise tolerance in 33 patients with exercise-induced angina with varying adrenergic vasoconstriction during exercise estimated by responses to pratsiol. The effect was found to be related to the degree of functional vasoconstriction. It is concluded that there is a pathogenetic heterogeneity of angina on effort in which in 57% of patients having high coronary reserve, adrenergic vasoconstriction along with organic changes in of great value in the genesis of myocardial ischemia during exercise. In 33% patients with low coronary reserve, the major role is played by organic changes in the coronary bed and vasoconstrictive responses are unassociated with adrenergic exposure. Only in 12% of patients the functional component of coronary vasoconstriction is lacking.

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Circulation; Drug Evaluation; Exercise Test; Exercise Tolerance; Hemodynamics; Humans; Middle Aged; Physical Exertion; Vasoconstriction

The examination of 208 patients with stable exercise-induced angina has demonstrated that the long-term (12 weeks and 12 months) antianginal effect can be predicted with a high accuracy from the results of acute pair exercise test using the drugs. The negative result of the test with verapamil is not informative due to the accumulation of its antianginal effect when the agent is used long. The long-term antianginal effect of nitrosorbide is determined not only by positive pair exercise test, but mainly by its dosage regimen during a day. The fact that half the patients who took labetalol for a long time developed tolerance to its anginal effect casts some suspicion on the advisability of its administration in stable angina. Lipid peroxidation as a mechanism of platelet aggregability regulation.

Topics: Angina Pectoris; Cardiovascular Agents; Exercise Test; Exercise Tolerance; Humans; Myocardial Ischemia; Physical Exertion; Predictive Value of Tests; Prognosis; Time Factors

Topics: Angina Pectoris; Attitude to Health; Cardiovascular Agents; Exercise Test; Humans; Prognosis

Topics: Adrenergic beta-Antagonists; Adult; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Chronic Disease; Dose-Response Relationship, Drug; Drug Evaluation; Exercise Test; Humans; Male; Middle Aged; Nitrates; Physical Exertion

Topics: Angina Pectoris; Cardiovascular Agents; Exercise Test; Humans; Risk Factors

Nitrates, molsidomin, betablockers, calcium antagonists, inhibitors of platelet aggregation and anticoagulants are the most important drugs for the management of the different forms of angina pectoris. Their use in chronic stable, unstable and vasospastic angina pectoris and for secondary prophylaxis are discussed.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Fibrinolytic Agents; Humans; Molsidomine; Nitrates

A study was made of the clinical course of angina pectoris and of the efficacy of the basic antianginal drugs in patients with coronary heart disease, undergoing aortocoronary shunting (ACS). After the surgical treatment angina pectoris ran a typical course in the majority of cases. It was marked by a favourable clinical course and was amenable by medicamentous correction. According to the results of acute pharmacodynamic tests, monotherapy turned out effective in 120 patients (72.3%), combined therapy in 31 patients (18.7%). The desirable results were attained only in 15 subjects (9.0%). It is recommended that these patients may be subjected to repeated ACS. From the viewpoint of evaluating certain drug groups, preference should be given to mono- and combined therapy with calcium antagonists.

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Drug Evaluation; Drug Therapy, Combination; Electrocardiography; Exercise Test; Humans; Male; Middle Aged; Physical Exertion; Postoperative Care

Topics: Angina Pectoris; Cardiovascular Agents; Contraindications; Humans

A study was made of the effect of beta 1-adrenoblockers (metoprolol, atenolol, talinolol) on bronchial patency in patients with concomitant bronchial asthma (BA) under acute drug use and in the course of continuous therapy. Broncho-obstructive complications occurring in part of the patients were not associated with the disease gravity or with the pathogenetic variety of BA. Besides, they were not associated with the drug dose either (use was made of the mean therapeutic dosage range). The rate and the intensity of bronchial patency abnormalities occurring in the course of the continuous treatment with beta 1-adrenoblockers (with metoprolol, in particular) depended on the initial status of the adrenergic regulation of the body. Significant disorders of bronchial patency including clinically marked ones were naturally observed with initially low excretion of cAMP in the morning portion of urine (less than 3 mmole/1).

Topics: Administration, Sublingual; Adrenergic beta-Antagonists; Angina Pectoris; Asthma; Bronchi; Cardiovascular Agents; Coronary Disease; Drug Evaluation; Humans; Middle Aged; Time Factors

Topics: Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Diet Therapy; Exercise Therapy; Humans

A number of cardiotropic preparations (verapamil, obsidan, pyroxan) were studied in glycerinated fibres (GF) in the experiments on rats during five twenty four hours after ligation of coronary artery. Their ability in different degree to preserve cardiomyocyte contractile fibers from the injury of ischemic processes is revealed. Positive influence of antianginal therapy was also confirmed in the experiments with coronary artery ligation on awake animals, and in experiments on the identification of actomyosin complex components.

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Coronary Disease; Disease Models, Animal; Drug Evaluation, Preclinical; Glycerol; Heart; Male; Myocardial Contraction; Myocardium; Rats

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Nitroglycerin

Topics: Angina Pectoris; Cardiovascular Agents; Exercise Test; Humans; Myocardial Infarction

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Disease; Drug Evaluation; Humans; Male; Middle Aged; Physical Exertion; Time Factors

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Humans; Nitrates

Although unstable angina is an extremely common and often initial manifestation of coronary disease, few controlled studies of its treatment have been carried out. This relative dearth of information is due to the methodological problems raised by the evaluation of unstable angina. Unlike the definition of myocardial infarction, that of unstable angina--i.e. of a population of coronary patients who from time to time are at a high risk of myocardial infarction or death--is neither unequivocal nor easy to standardize. It follows that the patient population ultimately selected for controlled trials is but a small part of all unstable angina patients. The representativeness of patients involved in therapeutic trials is probably approximate. Moreover, the current criteria for assessment of effectiveness are either the clinical signs of angina in the short term or the incidence of myocardial infarction and changes in survival curves in the mid- and long terms. A more precise definition of criteria of inclusion, leading to an homogeneous population, and the development of a simple and reliable method for detecting and quantifying myocardial ischaemia, both being used as intermediate criteria of assessment, would undoubtedly improve the quality of therapeutic trials in unstable angina and, mostly, their applicability to daily therapeutic practice.

Topics: Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Clinical Trials as Topic; Coronary Angiography; Coronary Disease; Exercise Test; Humans

In isolated perfused guinea pig hearts and in the cardiocirculatory system of anaesthetized rabbits the thromboxane A2-agonist U 46619 shows cardiodepressive effects. The contraction force of isolated auricle preparations from guinea pigs was enhanced. Antianginous drugs (dipyridamole, propranolol, verapamil, nitroglycerin and trapidil) induced a significant inhibition of the U 46619 effects. Oxyfedrine remained ineffective. The efficiency of some derivatives of trapidil was markedly diminished or abolished in comparison with the original substance. Because of the different chemical structure of the active drugs the TXA2-antagonism is regarded to be caused by a functional influence on the cellular membrane and the calcium transport. Nevertheless the inhibition of the TXA2-effects by antianginous drugs seems to be a factor for the therapeutic use of these substances.

Topics: Anesthesia; Angina Pectoris; Animals; Anti-Arrhythmia Agents; Blood Pressure; Cardiovascular Agents; Coronary Vessels; Dipyridamole; Guinea Pigs; In Vitro Techniques; Muscle Contraction; Muscle, Smooth, Vascular; Myocardial Contraction; Pyrimidines; Rabbits; Thromboxane A2; Trapidil

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Heart Failure; Humans; Hypertension

The effects of the bradycardic agent UL-FS 49 on hemodynamic and segmental parameters were studied in a canine model of exercise-induced myocardial dysfunction which mimics exercise-induced angina pectoris. Ten dogs, trained to subunit to five treadmill exercise cycles consisting of 4 min of running and 11 min of recovery, were chronically instrumented with a microtip manometer in the left ventricle, two pairs of crystals for sonomicrometry, a hydraulic occluder around the circumflex branch of the left coronary artery and arterial and venous catheters. Control experiments with coronary stenosis clarified the reproducibility of exercise-induced regional contractile dysfunction and recovery of function in the intervening resting periods. In each individual dog, a similar degree of stenosis was used in the subsequent experiments with UL-FS 49. After two control runs, which exhibited regional contractile dysfunction of comparable magnitude, UL-FS 49 was administered intravenously at a dosage of 0.5 mg/kg/5 min (6 dogs) or 0.25 mg/kg/5 min (4 dogs). Both doses of UL-FS 49 markedly reduced heart rate without alteration of left ventricular positive dp/dtmax at rest and during exercise. A marked improvement of regional function in the area perfused by the stenosed coronary artery was also observed during exercise. This beneficial effect of selective bradycardia, here observed with UL-FS 49, remains to be confirmed in clinical trials.

Topics: Angina Pectoris; Animals; Benzazepines; Blood Pressure; Cardiovascular Agents; Disease Models, Animal; Dogs; Exercise Test; Female; Heart Rate; Hemodynamics; Male; Myocardial Contraction

A total of 349 patients with vasospastic angina were followed in eight centers in Japan for a period of 3.4 +/- 0.1 years (mean +/- SE). Ninety-eight percent of patients were treated with calcium blockers. Twenty-one episodes of myocardial infarction occurred in 18 patients (5%), including two fatal myocardial infarctions. The rate of myocardial infarction was higher (p less than .01) in patients with a fixed stenosis of 90% or greater than in patients with a fixed stenosis of less than 90% or normal coronary arteries. Myocardial infarctions occurred predominantly during hospital stays or at a time when the frequency of vasospastic angina increased. There were five sudden deaths (2%). Only one patient suffering sudden death had a fixed stenosis of 75% or greater. Serious arrhythmias were noted in 49 patients (14%). The risk of arrhythmias did not depend on the presence of a fixed stenosis of 75% or greater. These results suggest that cardiac events are rather infrequent in Japanese patients with vasospastic angina who are receiving treatment with calcium blockers and that the presence of a severe fixed stenosis markedly increases the risk of myocardial infarction but not the risk of arrhythmias.

Topics: Adult; Aged; Aged, 80 and over; Angina Pectoris; Arrhythmias, Cardiac; Calcium Channel Blockers; Cardiovascular Agents; Coronary Vasospasm; Death, Sudden; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Japan; Male; Middle Aged; Myocardial Infarction; Risk

This paper describes the inhibitory effects of several antianginal drugs on 22Na uptake of the fast Na+ channel in rat brain synaptosomes and in rat heart muscle cells in culture. Calcium antagonists like verapamil, flunarizine, perhexiline, two perhexiline derivatives IPS 629 and IPS 672, and beta-adrenoceptor antagonists like propranolol and practolol were tested. IPS 672 was the most active compound on synaptosomes and heart muscle cells (IC50 = 2.0 X 10(-6) and 2.4 X 10(-6) M respectively). The relative potencies of the Ca2+ antagonists tested on heart muscle cells were found to be IPS 672 greater than IPS 629 greater than perhexiline greater than flunarizine greater than verapamil. Verapamil was 55 and 10 times less active than IPS 672 on synaptosomes and heart cells respectively. Propranolol had an inhibitory activity comparable to that of flunarizine and was 100 times more active than practolol. It can be concluded that several antianginal drugs seems to interfere with the Na+ fast channel on rat brain and heart.

Topics: Angina Pectoris; Animals; Brain Chemistry; Cardiovascular Agents; Cells, Cultured; In Vitro Techniques; Male; Myocardium; Neurotoxins; Rats; Rats, Inbred Strains; Sodium; Sodium Radioisotopes; Synaptosomes

Topics: Age Factors; Aged; Angina Pectoris; Cardiovascular Agents; Humans

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Disease; Drug Evaluation; Electrocardiography; Epoprostenol; Exercise Test; Female; Humans; Iloprost; Male; Middle Aged; Syndrome

A prospective five-year study and medicinal treatment were conducted in 317 coronary patients with stable angina in the absence of any signs of heart failure, and stenosing coronary arterial atherosclerosis as evidenced by selective coronary angiography. Total mortality was 2.8%, and the incidence of documented non-fatal myocardial infarction was 3.8% per year. The mortality was mostly dependent on the severity of angina's functional class and the number of affected major coronary arteries (narrowed by more than 70%). A group of patients with unfavorable prognosis was identified (functional class III to IV, low physical stress tolerance, the involvement of two or three major coronary arteries). The results demonstrate the efficiency of long-term medication in coronary patients with stable angina due to stenosing coronary atherosclerosis.

Topics: Adult; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Artery Disease; Coronary Disease; Drug Therapy, Combination; Electrocardiography; Humans; Male; Middle Aged; Prognosis; Prospective Studies

Topics: Angina Pectoris; Cardiovascular Agents; Coronary Disease; Drug Therapy, Combination; Humans; Time Factors

Paired bicycle ergometry was used in 24 anginal patients to compare the efficiency of 10-20 mg isosorbide dinitrate, 20-30 mg corinfar and 40-80 mg propranolol. Isosorbide dinitrate showed maximum efficiency in half of the patients, corinfar in 1/4, propranolol in 1/6. Isosorbide dinitrate produced an effect with the very first dose more frequently, as compared to other drugs. Heart rate patterns at rest and under the action of corinfar and isosorbide dinitrate varied in different individuals and were related to the time of onset of an exercise-induced anginal attack.

Topics: Angina Pectoris; Cardiovascular Agents; Drug Evaluation; Exercise Test; Hemodynamics; Humans; Isosorbide Dinitrate; Male; Middle Aged; Nifedipine; Physical Endurance; Propranolol

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Humans; Nitrates

Topics: Angina Pectoris; Anti-Arrhythmia Agents; Antihypertensive Agents; Arrhythmias, Cardiac; Cardiotonic Agents; Cardiovascular Agents; Cardiovascular Diseases; Fibrinolytic Agents; Hemodynamics; Humans; Hypertension; Platelet Aggregation; Thrombosis

Topics: Angina Pectoris; Assisted Circulation; Cardiovascular Agents; Diagnosis, Differential; Drug Therapy, Combination; First Aid; Humans; Plasma Substitutes; Shock, Cardiogenic

Alinidine is a new sinus node inhibitor which does not interact with the beta adrenergic receptors. Its haemodynamic effects were studied in 57 patients; 24 with unstable angina, 9 with myocardial infarction and heart rate greater than 100 bpm but without heart failure. 10 with myocardial infarction treated with vasodilators and 14 with severe heart failure or shock. After dosages up to 40 mg alinidine, heart rate decreased by 14 +/- 7 bpm, mean arterial pressure was reduced by 3 +/- 6 mmHg, stroke volume remained unchanged while cardiac output decreased 0.5 +/- 0.61 min-1 and systemic vascular resistance increased. Signs of heart failure developed in 3 patients, although overall left ventricular filling pressure remained unchanged. The haemodynamic response to alinidine warrants further studies of its efficacy in patients with angina or sinus tachycardia.

Topics: Adult; Aged; Angina Pectoris; Angina, Unstable; Cardiac Output; Cardiovascular Agents; Clonidine; Female; Heart Rate; Hemodynamics; Humans; Male; Middle Aged; Myocardial Infarction

Topics: Angina Pectoris; Angina, Unstable; Cardiovascular Agents; Coronary Disease; Humans; Myocardial Infarction

Topics: Angina Pectoris; Cardiovascular Agents; Diagnosis, Differential; Humans; Male; Middle Aged; Pleurisy

The medical management of angina pectoris requires a comprehensive approach to the patient and his family, including attention not only to established physiologic and pharmacologic principles, but also to the emotional aspects of his illness. When comprehensive management is systematically and rigorously applied to the patient with angina pectoris, excellent relief of the symptoms of angina pectoris can be achieved in a high percentage of patients, although there are significant numbers of patients who are refractory to the most intensive management using presently available drugs. The same fundamental principles of care apply to patients with coronary heart disease who undergo aortocoronary bypass surgery and to those treated medically.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Diagnostic Errors; Humans; Nitrates; Nitroglycerin; Patient Education as Topic; Prognosis; Risk

Topics: Angina Pectoris; Animals; Cardiovascular Agents; Chemical Phenomena; Chemistry; Dogs; Indolizines

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Disease; Heart Function Tests; Humans; Vasodilator Agents

Topics: Angina Pectoris; Angina Pectoris, Variant; Calcium; Cardiovascular Agents; Humans; Ion Channels; Muscle, Smooth, Vascular; Myocardial Contraction

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Pain; Risk

The medicamentous therapy of the angina pectoris vera and of the chronic ischaemic heart disease is at present based on three groups of medicaments: nitrate compounds, beta-blocking agents and calcium antagonists. The underlying therapeutic principle which is common for them consists in the reduction of the oxygen requirement of the myocardium so that an improvement of the complaints and a larger load capacity may be achieved. The improvement may be objectified also at the behaviour of the haemodynamics and the ECG under load. The so-called coronary dilating remedies and the beta-stimulators did not prove clinically. In the acute attack rapidly acting nitroglycerin compounds remain the remedies of choice. Also the permanent treatment should at first again use longer acting nitrate preparations. When despite a sufficient dosage no satisfying improvement takes place an additional prescription of beta-blocking agents is recommended. Calcium antagonists are suitable particularly for the vasospastic form of the angina pectoris. They can be used also as basis medicaments, however, according to the hitherto yielded experiences they do not possess any advantages in contrast to the proved nitrates and beta-blocking agents. When apart from the ischaemic heart disease a hypertension exists, the beta-blocking agents are particularly indicated. This is further important for certain forms of tachycardiac disturbances of rhythm, which partly also well response to calcium antagonists. In patients with disturbances of conduction (sinus node and atrioventricular nodes, bifascicular block) beta-blocking agents are contraindicated. If there are no signs of cardiac decompensation and radiologically the heart proves to be normally large, so there is no indication for the prescription of glycosides.

Topics: Adrenergic beta-Antagonists; Angina Pectoris; Arrhythmias, Cardiac; Calcium; Cardiovascular Agents; Coronary Disease; Digitalis Glycosides; Humans; Nitroglycerin; Vasodilator Agents

On the basis of clinical examination and the results of bicycle ergometry and echocardiography in 58 patients with chronic ischemic heart disease the authors determined the contingent of patients in whom long-acting nitrates were most effective. The high clinical effectiveness of the agents in patients with symptoms of the initial stage of cardiac insufficiency is proved and the absence of any essential differences between long-acting nitrates in the character of their effect on hemodynamics is shown. It is established that nitroglycerin and long-acting nitrates cause a qualitatively similar effect on myocardial contractile function and intracardiac hemodynamics in patients with ischemic heart disease.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Disease; Delayed-Action Preparations; Drug Evaluation; Female; Hemodynamics; Humans; Male; Middle Aged; Nitrates; Nitro Compounds; Nitroglycerin

Seventy-seven patients with chronic ischemic heart disease were treated in single-seater oxygen hyperbaric chambers; 52 patients had angina pectoris of effort or angina of effort and at rest while 25 patients with macrofocal postinfarction cardiosclerosis had insufficiency of pulmonary or systemic circulation. Treatment consisted of 12--15 procedures. The use of hyperbaric oxygenation in a complex with drug therapy makes it possible to alleviate or arrest the attack of angina pectoris and relieve considerably the symptoms of cardiac decompensation. The initial condition of central hemodynamics affects greatly the results of barotherapy. Normal parameters of hemodynamics hardly change after treatment. At the same time, in patients with markedly reduced myocardial contractility hyperbaric oxygenation causes evident positive changes in hemodynamics. The combination of hyperbaric oxygenation with drug therapy improves the effect of treatment significantly.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Disease; Drug Therapy, Combination; Evaluation Studies as Topic; Female; Heart Failure; Humans; Hyperbaric Oxygenation; Male; Middle Aged

Topics: Angina Pectoris; Cardiovascular Agents; Chest Pain; Chlordiazepoxide; Dipyridamole; Electrocardiography; Geriatrics; Humans; Pentaerythritol Tetranitrate; Prenylamine

Topics: Angina Pectoris; Biomedical Research; Cardiovascular Agents; Coronary Disease; Drug Therapy; Geriatrics; Muscle Relaxants, Central; Parasympatholytics; Placebos; Vasodilator Agents

Topics: Angina Pectoris; Cardiovascular Agents; Porphyrins

Topics: Angina Pectoris; Cardiovascular Agents; Chlordiazepoxide; Erythrityl Tetranitrate; Humans; Hydrazines; Imipramine; Isocarboxazid; Nialamide; Nitrates; Phenelzine

Topics: Adenine Nucleotides; Angina Pectoris; Cardiovascular Agents; Digoxin; Heart Failure; Humans; Nucleosides

Topics: Angina Pectoris; Cardiovascular Agents; Prenylamine; Vasodilator Agents

Topics: Angina Pectoris; Cardiovascular Agents; Epinephrine; Ergot Alkaloids; Nitrites; Oxytocics; Papaverine

Topics: Angina Pectoris; Cardiovascular Agents; Muscle Relaxants, Central; Vasodilator Agents

Topics: Angina Pectoris; Cardiovascular Agents; Erythrityl Tetranitrate; Humans; Nitrites; Nitroglycerin; Pentaerythritol Tetranitrate

Topics: Angina Pectoris; Benzofurans; Cardiovascular Agents; Electrocardiography; Furans; Humans; Vasodilator Agents

Topics: Angina Pectoris; Benzofurans; Biomedical Research; Cardiovascular Agents; Furans; Humans; Pentaerythritol Tetranitrate; Vasodilator Agents

Topics: Angina Pectoris; Cardiovascular Agents; Lactates; Prenylamine; Vasodilator Agents

Topics: Angina Pectoris; Cardiovascular Agents; Drug Combinations; Humans

Ergometrine usually depresses the S-T segment as in coronary insufficiency, when injected intravenously in rabbits with experimental coronary atherosclerosis and in patients with effort angina, but not in normal animals and man. To explain this difference, we carried out Langendorff perfusion studies in 32 normal and 29 atherosclerotic isolated rabbit hearts. Preliminary tests with ergometrine were done to ensure that advanced coronary atherosclerosis had developed in the rabbits fed a cholesterol diet; pathological examination of the heart after perfusion confirmed the result of the final test with ergometrine. Before drugs were perfused, the basal rate of coronary flow was greater, the heart rate was slower and the contractile amplitude was smaller in the atherosclerotic than in the normal hearts; nitroglycerin markedly increased flow in both normal and atherosclerotic groups. Ergometrine consistently caused a reduction in contractile amplitude with negligible changes in heart rate in both normal and atherosclerotic hearts. On coronary flow, however, the effects of ergometrine differed significantly in these groups; in doses of between 0.2 and 0.4 mg., the average decrease in flow was 8% in normal and 22% in atherosclerotic hearts. The effect was more variable in normal hearts and an increase in flow sometimes occurred. The difference in the response of normal and atherosclerotic hearts was particularly striking when ergometrine was given during recovery from a reduction of coronary flow which had been induced by vasopressin. Ergometrine then uniformly increased flow in the normal, but usually had the opposite effect in the atherosclerotic heart. In normal and atherosclerotic hearts, cardiac effects of vasopressin were similar. Tachyphylaxis to vasopressin, but not to ergometrine, was observed.

Topics: Angina Pectoris; Animals; Arginine Vasopressin; Cardiovascular Agents; Cholesterol, Dietary; Ergonovine; Ergot Alkaloids; Heart; Humans; Male; Oxytocics; Perfusion; Rabbits; Vasopressins

Topics: Angina Pectoris; Cardiovascular Agents; Humans

Topics: Amobarbital; Angina Pectoris; Barbiturates; Cardiovascular Agents; Nitrites

Topics: Angina Pectoris; Cardiovascular Agents; Humans

Topics: Angina Pectoris; Biological Assay; Cardiovascular Agents; Humans; Interpersonal Relations

Topics: Angina Pectoris; Cardiovascular Agents; Muscle Relaxants, Central

Topics: Angina Pectoris; Cardiovascular Agents; Electrocardiography; Nitrites

Topics: Angina Pectoris; Cardiovascular Agents; Chlorpromazine; Nitrites; Theophylline

Topics: Angina Pectoris; Cardiovascular Agents; Muscle Relaxants, Central; Parasympatholytics

Topics: Angina Pectoris; Cardiovascular Agents; Hexamethonium; Humans; Hyperinsulinism; Hypoglycemia; Insulin; Muscle Relaxants, Central

Topics: Angina Pectoris; Cardiovascular Agents; Electrocardiography; Ergoloid Mesylates; Ergot Alkaloids; Oxytocics

Topics: Analgesics; Angina Pectoris; Cardiovascular Agents; Muscle Relaxants, Central; Promedol

Topics: Angina Pectoris; Cardiovascular Agents; Ergonovine; Ergot Alkaloids; Ethyl Chloride; Humans; Oxytocics; Pain

Topics: Angina Pectoris; Brain; Cardiovascular Agents; Khellin; Muscle Relaxants, Central; Parasympatholytics; Vasoconstrictor Agents; Vasodilator Agents

Topics: Angina Pectoris; Cardiovascular Agents; Humans; Muscle Relaxants, Central; Papaverine

Topics: Amines; Angina Pectoris; Cardiovascular Agents; Muscle Relaxants, Central

Topics: Angina Pectoris; Cardiovascular Agents; Cyclandelate; Hypertension; Muscle Relaxants, Central

Topics: Angina Pectoris; Cardiovascular Agents; Ergot Alkaloids; Humans; Oxytocics