Management of Ischemic Heart Disease: Therapeutic Options and Future Directions–Official Satellite Symposium to the XVIIth Congress of the European Society of Cardiology

Abstract

This symposium opened with the presentation of information that will be of assistance in the development of future diagnostic strategies and therapy in angina pectoris. As the principal symptom of ischemic heart disease (IHD), angina requires accurate and prompt diagnosis to enable effective treatment. For example, one common assumption is that a patient may be typically perceived of as a middle-aged man with effort angina, often associated with other illnesses. However, data presented by Dr. Pepine, from a study in 5125 U.S. outpatients, suggests that patients are most likely to be women and the elderly, with high levels of associated illnesses. Despite the availability of a number of surgical and medical therapies, IHD remains a serious health problem. The issue of the relative costs of surgical and medical therapies has been studied by Dr. Cleland through a cost–bene~t and cost-effectiveness analysis model in a hypothetical cohort of 100 patients. The degree of symptom control was a signi~cant determinant in choice of therapy. In patients with well-controlled symptoms, medical therapy offers the most costeffective option. In particular, calcium antagonists, beta-blockers, and long-acting nitrates have formed the mainstay of antiischemic management of IHD. A rational approach to the treatment of chronic myocardial ischemia requires an understanding of the pathophysiology of coronary artery disease and the treatment options available. These two issues are discussed in detail by Dr. Cohn, including the use of combination therapy and new agents under investigation. One of the aims of improving current therapy should be to reduce unwanted interactions, for example, by careful combination of particular classes of drug. Traditional calcium antagonists, in particular, have been associated with a number of side effects, such as headache and _ushing, caused by abrupt vasodilation. The new generation of dihydropyridine calcium antagonists may offer an effective alternative to the original calcium antagonists or beta-blocking drugs because of their improved pharmacodynamic and pharmacokinetic pro~le. This ef~cacy is demonstrated by the multicenter, double-blind study of Dr. van Kesteren, which compared amlodipine with controlled-release diltiazem in 132 patients. The results show bene~ts to both groups of patients, with reduced numbers of withdrawals and adverse events seen in the amlodipine group. Overall, the ef~cacy, tolerability, and once-daily dosing may favor the use of third-generation calcium channel blockers, such as amlodipine, in the treatment of coronary artery disease. Twenty-four hour coverage can improve patient compliance and, more importantly, can provide anti-ischemic control during those periods of the day when there are high rates of ischemic attack. The Circadian Anti-ischemia Program in Europe (CAPE) trial recently showed that, compared with placebo, amlodipine added to background therapy signi~cantly reduced both symptomatic and asymptomatic ischemia over 24 hours in patients with chronic stable angina. The aims of the ongoing CAPE II trial are to compare the effects of amlodipine with diltiazem in treating ischemia, to investigate the ability of these two drugs to manage the circadian pattern of myocardial ischemia, and to evaluate combined therapy of amlodipine plus a betablocker and diltiazem plus a nitrate. The results from this study will demonstrate the optimal medical approach to ischemia suppression in patients with coronary artery disease and add further support to the use of calcium antagonists in future therapeutic recommendations.