Chronic Stable Angina Research Articles

Abstract P106: Association of Race and SES with the Treatment of STEMI and NSTEMI and the Rate of Coronary Revascularization among Post-Menopausal Women: The Women Health Initiative

Background: Racial disparities in coronary revascularization have been documented. However, it is unclear whether these disparities are consistent on a national basis among post-menopausal women hospitalized with STEMI and NSTEMI or for chronic stable angina. Our objective was to assess racial and potential SES disparities in emergent treatment of STEMI, revascularization of STEMI, NSTEMI and for any indication among white, blacks and Hispanic post-menopausal women. Methods: We used data from the 133,760 post-menopausal women, 11,843 were African-American, 4,875 Hispanic, and 117,042 Caucasian. We compared rates of emergent therapy and of coronary revascularization by race and SES. Emergent therapy is defined as thrombolysis, PCI or CABG within 12 hours of chest pain. PCI and CABG any time during a hospitalization were determined by trained physician adjudicators of hospitalized medical records triggered by participant annual self-report. Low SES was defined as less than a high school education or a household income of less than $20,000. Age-adjusted proportional hazards models were performed to evaluate potential disparities in outcomes. No additional covariate adjustment was performed as established CHD risk factors, insurance status, geography are potential causal mediators of the disparities evaluated. Results: Overall, Black women (HR=0.75, 95% CI 0.68-0.82) and Hispanic women (HR=0.69, 95% CI 0.60-0.80) received less revascularization regardless of indication. Black women received less revascularization during a MI hospitalization (HR=0.74, 95% CI 0.62-0.89). For STEMI, Black women received less emergent therapy (HR=0.61, 95% CI 0.48-0.79), less non-emergent revascularization (HR=0.53, 95% CI 0.33-0.86) and overall less revascularization regardless of timing (HR=0.54, 95% CI 0.39-0.75). The number of events in Hispanics precluded analysis. For NSTEMI, no difference by race was found (HR= 0.88, 95%CI 0.70-1.10). Overall, women with low SES received more revascularization (HR=1.40, 95% CI 1.32-1.48) regardless of indication. For STEMI, low SES women compared to high SES received more emergent therapy (HR=1.19, 95% CI 1.03-1.39), and a trend towards more non-emergent revascularization (HR=1.11, 95% CI 0.86-1.44) and revascularization regardless of timing (HR=1.14, 95% CI 0.96-1.37). For NSTEMI, low SES women received more revascularization (HR=1.21, 95% CI 1.04-1.41) than high SES women. Conclusions: There appear to be health disparities with regards to race in emergent therapy for STEMI and revascularization for STEMI, MI and any indication in post-menopausal women. We observed an inverse association between revascularization rates and SES suggesting that other factors may need to be considered to explain this relationship. Mediation analyses to better understand the causal factors associated with our findings need to be explored.

CONFIRMATIVE PHASE III GLOBAL CLINICAL TRIAL OF A BOTANICAL DRUG IN PATIENTS WITH CHRONIC STABLE ANGINA (CAESA): NEW TREATMENT OPTIONS FOR MYOCARDIAL ISCHEMIA HEART DISEASE

T89, a 3-herb composition drug that improves microcirculation in and increase energy supply to the heart, and reduces blood viscosity in patients with chronic stable angina (A) has been shown to improve clinical outcomes in comparison to current anti-anginal drug (CAAD) such as β-blockers, Ca++

A “FUNNY” WAY TO TREAT CARDIOGENIC SHOCK: A CASE SERIES

Ivabradine is a funny current channel (If) inhibitor approved for managing sinus tachycardia in chronic stable angina and chronic heart failure with cardiac ejection fraction of less than 35%. There is currently limited data supporting its use in the setting of acute decompensated heart failure or

Role of the Funny Current Inhibitor Ivabradine in Cardiac Pharmacotherapy: A Systematic Review.

The pharmacology, pharmacokinetics, efficacy and safety of ivabradine are reviewed. Ivabradine is an oral medication that directly and selectively inhibits the hyperpolarization-activated cyclic-nucleotide gated funny (If) current in the sinoatrial node resulting in heart rate reduction. It has a plasma elimination half-life of 6 hours and is administered twice daily. Ivabradine is extensively metabolized by cytochrome P450 3A4, and its metabolism is affected by inducers and inhibitors of the 3A4 enzyme. Studies in patients with heart failure indicate that ivabradine improves surrogate markers such as exercise tolerance. The results of (1) phase III trial demonstrated ivabradine significantly reduced heart failure hospitalizations but had no effect on mortality. Ivabradine has been extensively evaluated for coronary artery disease wherein (2) large trials was shown to have no mortality benefit. Ivabradine has been associated with improved symptoms in stable chronic angina pectoris. Ivabradine has been evaluated for other cardiovascular conditions including tachycardias of various natures, arrhythmia prevention postcardiac surgery, in acute coronary syndrome, and for heart rate control during coronary computed tomography angiogram. The most common adverse events reported in clinical trials were bradycardia, new-onset atrial fibrillation, and phosphenes. Ivabradine, a novel cardiac medication, has been studied in numerous cardiac conditions. It is only currently approved in the United States to reduce hospitalizations for systolic heart failure. The role of this medication in other conditions has not been fully elucidated.

Assessment of left and right atrial geometrical changes in patients with stable coronary artery disease: Left and right atrial strain and strain rate imaging study.

ObjectiveIn patients with coronary artery disease (CAD), there are several studies that assessed the left ventricular (LV) function by strain (S) and strain rate (SR) imaging. The aim of this study is to evaluate the function of both atria in patients with CAD using strain and strain rate imaging, and to correlate this with the severity of CAD.MethodsWe conducted a prospective, single center case control study for 40 consecutive patients who presented to our department with chronic stable angina and were candidates for invasive coronary angiography. We enrolled patients from December 2013 to May 2014 and each patient was subjected to echocardiographic assessment of E/e′ of mitral valve, left atrial volume index (LAVI), right atrial volume index (RAVI), and peak atrial longitudinal strain (es) and strain rate (SR) during LV systole. This was followed by invasive coronary angiography for assessment of the severity of CAD using Gensini score. Patients were classified according to angiographic results into 3 groups: Group I (Gensini score = zero), Group II (Gensini score > 0 and < 20) and Group III (Gensini score ≥ 20).ResultsThere was no statistically significant difference between the three groups in either LA volumes (Vmin, Vmax) and distensibility with p value of 0.272, 0.126, and 0.243 respectively or RA volumes and distensibility with a p value of 0.671, 0.183, and 0.259 respectively. On the other hand, LA & RA systolic S and SR were significantly lower among CAD patients in comparison with the group of normal coronaries. Mean LA S and SR was decreased in group III than group II (15.97 ± 3.73, 21.8 ± 6.75 % and 1.11 ± 0.30, 1.81 ± 1.23 s−1) with p value of 0.005&0.041 respectively. RA systolic S and SR were significantly lower in the 2 groups with CAD than the group with normal coronaries with a p value of 0.001 and 0.002 respectively.ConclusionIn patients with CAD and normal EF, borderline E/e′ ratio and normal atrial size, there are decreased LA and RA systolic S and SR parameters with no effect on atrial volumes or distensibility. Accordingly, this could prove that atrial wall deformation occurs early in CAD even before any changes in atrial volumes or dimensions.

The relationship between the bilirubin and the severity of coronary artery disease (CAD) in patients with chronic stable angina

BackgroundIndeed, previous studies have been reported that mildly elevated bilirubin levels in Gilbert's syndrome are associated with lower ischemic heart disease risk compared with general population.1 Also, a recent study revealed by Gul et al. that total bilirubin levels independently predict adverse cardiac events in ST-segment elevation myocardial infarction (STEMI) patients who undergo primary percutaneous coronary intervention (PCI),2 the present study focused on studying the role of bilirubin and its relationship with the severity of CAD. Patents and methodsWe included 102 consecutive patients presented with chronic stable angina were referred for elective coronary angiography in our Cath. Lab. Then complete history was taken, general and local examination was done, blood sample was taken for laboratory tests with special attention to serum total bilirubin, indirect bilirubin and direct bilirubin, resting 12 lead ECG (evidence of ischemia) and bedside screening ECHO (EF, LV dimensions and WMA) was done on admission. Lastly, coronary angiography was performed after obtaining informed consent coronary angiograms, GENSINI score and SYNTAX score were examined by two experienced interventional cardiologists who were blinded to the clinical characteristics and laboratory results of the patients. ResultsThe serum total bilirubin has a cutoff value for prediction of severe CAD=0.595mg/dl with a sensitivity 86% and specificity 84%. The serum indirect bilirubin level has a cutoff value for prediction of severe CAD=0.395mg/dl with a sensitivity 76% and specificity 85%. Combination of TB and IB cutoff values for prediction of the severe coronary artery disease will raise the specificity of the tests from 84% and 85% respectively to 87%. ConclusionSerum total and indirect bilirubin have a role for prediction of severe CAD in patients with chronic stable angina.

The effects of Melissa officinalis (lemon balm) in chronic stable angina on serum biomarkers of oxidative stress, inflammation and lipid profile.

Coronary artery disease (CAD) is a major cause of death worldwide. Chronic stable angina (CSA) is the primary sign of CAD. Oxidative stress and inflammation play a substantial role in pathogenesis and progression of CAD. The aim of this study was to investigate the effects of oral administration of powdered Melissa officinalis (MO) on biomarkers of oxidative stress, inflammation, and lipid profile in patients with CSA. A randomized, double-blind, placebo-controlled clinical trial was performed in 80 patients with CSA. The subjects were randomly assigned to obtaineither oral MO 3 g/d (n=40) or placebo (n=40) for eight weeks. Anthropometric indices, biomarkers of oxidative stress, inflammation, and lipid profile were evaluated at baseline and post-intervention. The mean serum concentrations of triglycerides, total-cholesterol, LDL-cholesterol, and malondialdehyde (MDA), and high sensitive C-Reactive Protein (hs-CRP) were lower in the intervention group compared with placebo (p<0.01) post intervention. Moreover, the mean serum concentration of paraxonase 1 (PNO1) and HDL-c were higher (p<0.001) in the intervention group compared with the control group. Oral MO supplementation improves the lipid profile, MDA, hs-CRP, and PNO1 in patients with CSA.

Impact of Type II Diabetes on the Presentation of Coronary Artery Disease and Outcomes of Percutaneous Coronary Intervention in Female Patients

Abstract Background Coronary artery disease (CAD) is a well-established complication of type II diabetes mellitus affecting both men and women worldwide. A vast amount of research has shown evidence of increased risk for CAD in patients with type II diabetes compared with the general population and that this increased relative risk is more prevalent in women. The primary aim of this study is to observe the impact of type II diabetes on the severity of CAD at the time of presentation and also on the outcomes of CAD after PCI (percutaneous coronary intervention) in female patients. Methods A prospective single-center study for the period of 1 year, including 267 female CAD patients who underwent PCI was conducted. The patient population was divided into two major groups of which 171 (64%) patients had type II diabetes (group A) and 96 (36%) patients were nondiabetic (group B). The clinical presentations of CAD in type II diabetics and nondiabetics were compared in the form of chronic stable angina (CSA), acute coronary syndrome (ACS), left ventricular (LV) dysfunction, renal dysfunction, and the number of vessels involved. Primary outcomes were compared in the form of major adverse cardiovascular events (MACE), whereas secondary outcomes were compared in the form of statin-induced myopathy, also referred to as contrast-induced nephropathy (CIN). Results At presentation, 60 (35.08%) of 171 female patients with type II diabetes (group A) had CSA and 121 (70.76%) had ACS. Baseline creatinine was determined to be 1.17 ± 1.02 mg/dL amongst the participants. Moreover, 51 (29.8%) patients were observed to have LV dysfunction. The total number of lesions treated in this group was 237. Among group B, that is, 96 nondiabetic female patients, 62 (64.5%) patients had CSA, 34 (35.4%) had ACS, 39 (40.6%) had LV dysfunction, the baseline creatinine was (0.95 ± 0.39) mg/dL. The total number of lesions treated was in this group was 130.The difference in incidence of CSA, ACS, and renal dysfunction was statistically significant with p = 0.000, 0.000, and 0.016, respectively. The incidence of CSA was greater in group B, that is, nondiabetics; whereas, the incidence of ACS and renal dysfunction was found to be greater in group A, that is, type II diabetics. Moreover, the number of vascular territories involved was found to be more in patients with type II diabetes. Although, the incidence of severe LV dysfunction was greater in patients with type II diabetes, the difference was not statistically significant.When considering 1 year outcomes in female patients with type II diabetes, three cases of deaths, one case of acute stent occlusion, one subacute stent occlusion, one periprocedural myocardial infarction (MI), one CSA, one statin-induce myopathy, and one rhabdomyolysis are reported. Whereas, in nondiabetic female patients, one case of death, one CSA, one CIN, one chronic thrombus right radial artery, and one pseudoaneurysm and rupture are reported. Conclusion The results from this study suggest that in female patients with CAD, ACS presentation is more common in type II diabetes; whereas, CSA presentation is more common in nondiabetics. Moreover, multi-vessel involvement is more common in type II diabetes. Following PCI, there has been an increase in the prevalence of MACE, statin-induced myopathy and rhabdomyolysis in patients with type II diabetes. In conclusion, type II diabetes has been reported to significantly influence the severity of presentation, number of lesions involved, and complications following PCI.

Rationale and design of the ranolazine PH–RV study: a multicentred randomised and placebo-controlled study of ranolazine to improve RV function in patients with non-group 2 pulmonary hypertension

IntroductionA major determining factor on outcomes in patients with pulmonary arterial hypertension (PAH) is right ventricular (RV) function. Ranolazine, which is currently approved for chronic stable angina, has been shown...

Correlation of endothelial dysfunction measured by flow-mediated vasodilatation to severity of coronary artery disease

ObjectivesBrachial artery ultrasound imaging during reactive hyperemia is widely used tool for quantifying endothelium dependent vasomotion. Angiodefender device is used for non invasive determination of percentage flow mediated vasodilation (FMD). An attempt is made to study whether endothelial dysfunction determined by FMD of brachial artery predicts the presence or absence of coronary artery disease and its correlation with the severity of coronary artery disease. MethodsOne hundred six patients admitted between May 2014 and April 2015 who were posted for coronary angiography diagnosed to have chronic stable angina on clinical basis and/or by exercise stress test, for evaluation of coronary artery disease were submitted to standard clinical evaluation, calculation of percentage FMD by Angiodefender device. Statistical significance of difference of categorical variables was tested using Fisher’s exact test. Sensitivity, specificity, positive predictive value and negative predictive value of FMD were studied. ResultsThere was no correlation between number of risk factors and percentage of FMD. Significantly higher proportion of cases with less FMD had higher prevalence of coronary artery disease and vice-versa. Significantly higher proportion of cases with positive stress test had less percentage of FMD and vice-versa. Significantly higher proportion of cases with less percentage of FMD and positive stress test had higher prevalence of obstructive coronary artery disease and vice-versa. Specificity was 100% when percentage of FMD was ≤10. ConclusionsFMD an inexpensive and non-invasive test provides information regarding extent and severity of coronary artery disease.

The association of polymorphic variants, rs2267788, rs1333049 and rs2383207 with coronary artery disease, its severity and presentation in North Indian population

BackgroundThe polymorphic alleles of APOA5 (rs2266788 (C), rs3135506 (G)), LPA (rs10455872 (A), rs3798220 (G)) and 9p21.3 (rs1333049 (C), rs2383207(A)) have been reported in association with susceptibility of coronary artery disease (CAD) from genome wide association studies. We aimed to assess the association of genetic variants with coronary angiogram proven CAD, severity scored with modified Gensini score and association of risk for myocardial infraction (MI) in North Indian population. MethodsWe recruited 512 angiographic proven CAD patients (mean age 58.1±10.2years) and 272 controls (mean age 50.3±11.1years) with normal coronaries from North Indian population. The genotyping technique polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was employed for rs2266788, rs3135506 and rs10455872. Amplified refractory mutation system-PCR (ARMS-PCR) was used for genotyping of rs1333049, rs2383207 and rs3798220 genetic variants. ResultsThe polymorphic risk allele of variants rs2266788 (C), rs1333049 (C), rs2383207 (A) and heterozygous polymorphic alleles of rs2266788 (TC) were significantly associated with CAD. The homozygous alleles of rs22667788 (CC) and rs1333049 (CC) had also been significantly associated with CAD. The significance of association of rs2266788 (C, CC, TC) and rs1333049 (C, CC) increases with severity of CAD. The presence of mutant allele of rs2266788 (C) was associated with risk of MI and unstable angina (UA). Also, homozygous risk allele of rs2266788 (CC) significantly associated with risk of MI and UA in patients of chronic stable angina (CSA) patients. Whereas, the risk allele of rs1333049 (C) have shown the association with MI and UA compared to controls. The genetic variants of rs3135506 (G), rs10455872 (A) and rs3798220 (G) have low frequency in our population and reflected no association with CAD. ConclusionThe polymorphic variants of Apo-A5; rs2266788 (C), 9p21.3; rs1333049 (C) rs2383207 (A) are associated with CAD, its severity and exerts the risk of MI in North Indian population.

Effect of ranolazine on improvement of left ventricular dysfunction in patients with chronic stable angina: A randomized controlled clinical trial

Objectives: To study the effect of ranolazine on improvement of left ventricular (LV) dysfunction in comparison to trimetazidine in patients with chronic stable angina (CSA). Ranolazine is an anti-anginal agent that acts on the late inward sodium current and prevents pathologic intracellular calcium accumulation that leads to ischemia, myocardial dysfunction, and electrical instability. Methodology: After screening and obtaining informed consent, 29 patients with CSA who have sustained ST-Elevation Myocardial Infarction more than 12 weeks ago with LV ejection fraction (LVEF) ≤40% in a 2:1 ratio to receive ranolazine 500 mg BD (n = 19) or trimetazidine 35 mg BD (n = 10) were enrolled in the study. The patients were evaluated at the end of 8 weeks for the improvement in LV dysfunction by transthoracic echocardiography. Results: No significant difference was found in the baseline characteristics of the patients between the two groups except the increased body mass index among users of trimetazidine (26.3 ± 5.07 vs. 22.1 ± 3.26, P = 0.03). Study patients receiving ranolazine 500 mg BD for 8 weeks significantly improved the LVEF. No improvement was seen in diastolic function. Ranolazine was well tolerated among the patients. Conclusion: Ranolazine at a dose of 500 mg BD given for 8 weeks helps in improving the LVEF in patients with CSA and is a suitable option than trimetazidine among patients with CSA.

Longitudinal Strain Versus Exercise Treadmill Testing in Chronic Stable Angina

Background: Longitudinal strain analysis has been shown to be useful in patients with acute coronary syndromes and in stress echocardiography. The objective of this study is to identify the incremental diagnostic value of longitudinal strain analysis at rest, when added to routine treadmill testing (TMT), in identifying the presence of coronary artery disease in patients presenting with chronic stable angina (CSA). Methodology: We conducted a prospective study in which adult patients presenting with CSA and normal systolic function were enrolled. All patients were examined by 2-D echocardiography, longitudinal strain analysis, TMT, and either conventional coronary angiography and/ or coronary computed tomography angiography. Results: We enrolled a total of 150 subjects (54±7.8 years, 63% male). The sensitivity and specificity of TMT was 60.2% and 65.5% respectively. In comparison, global longitudinal strain (GLS) alone had better sensitivity (72.7%) and specificity (74.2%). Post-systolic shortening (PSS) had similar sensitivity for early detection of significant CAD. The combination of TMT and GLS provided the best overall diagnostic accuracy with a sensitivity of 85.4% and specificity of 87.5%, respectively. The optimal cut off for GLS for identification of coronary artery disease was −17.75%. Conclusions: In patients presenting with chronic stable angina and normal systolic function, global longitudinal strain and post systolic shortening assessed at rest have excellent diagnostic accuracy for coronary artery disease. Longitudinal strain analysis is superior to conventional TMT and adds to its diagnostic performance.

Clinical Profile of Patients With Chronically Occluded Coronary Arteries: A Single Center Study.

BackgroundA chronic total occlusion (CTO) is defined as an angiographically documented or clinically suspected complete interruption of antegrade coronary flow (Thrombolysis in Myocardial Infarction (TIMI)-0 flow) of greater than 3 months standing. Coronary CTOs represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. Decision to treat or not to treat a CTO is always confusing. This is an attempt to provide clinical profile of patients having totally occluded coronary arteries and their natural history.MethodsThe observational study was carried out in tertiary health center in Mumbai. Totally 117 patients who had CTO on angiography were selected. Their clinical presentation and angiography correlation was done and results were analyzed.ResultsOut of a total of 117 patients, 86 (73.50 %) were males, female 31(26%). All of the patients studied were above 40 years. Age group 40 - 49 years had 25 (21.36%) patients, 50 - 59 years had 32 (27.35%), 60 - 69 years had 43 (36.75%), > 70 years had 17 (14.52%) patients. Smoking as a risk factor was present in 32 (27.35%), tobacco in 45 (38.46%), alcohol in six (5%), no addictions in 35 (29.91%) patients. Diabetes in 63 (53.84%), hypertension in 78 (66.67%) patients, both were present in 49 (41.88%), dyslipidemia in 37 (31.62%) patients. Sixty-three (53.84 %) patients presented with unstable angina (UA)/non ST elevated myocardial infarction (NSTEMI), 32 (27.35%) with chronic stable angina (CSA), ST elevated myocardial infarction (STEMI) in 22 (18.80%). History of prior myocardial infarction (MI) was present in 36 (30.76%), prior coronary artery bypass graft (CABG) in nine (7.6%), prior percutaneous intervention (PCI) in 18 (15.38%). Triple vessel disease (TVD) in 38 (32.47%), double vessel disease (DVD) in 53 (45.29%), single vessel disease (SVD) in 26 (22.22%) patients. Left anterior descending artery (LAD) CTO was present in 40 (34.18%), right coronary artery (RCA) in 61 (52.14%), left circumflex artery (LCX) obtuse marginal (OM) in 16 (13.67%) patients.ConclusionsPatients having CTO of coronary arteries are mostly above age of 40 years. Most common age group was 60 - 69 years. It was most common in males than females. Tobacco chewing was more commonly associated followed by smoking. Hypertension and diabetes were strongly associated with CTO. Most patients presented with unstable angina/NSTEMI followed by chronic stable angina. Old MI was present in one third of patients. Most common artery to be affected was RCA followed by LAD.

Randomized controlled trials - mechanistic studies of testosterone and the cardiovascular system.

Testosterone deficiency is common in men with cardiovascular disease (CVD), and randomized placebo-controlled trials (RCTs) have reported beneficial effects of testosterone therapy on exercise-induced cardiac ischemia in chronic stable angina, functional exercise capacity, maximum oxygen consumption during exercise (VO2max) and muscle strength in chronic heart failure (CHF), shortening of the Q-T interval, and improvement of some cardiovascular risk factors. Testosterone deficiency is associated with an adverse CV risk profile and mortality. Clinical and scientific studies have provided mechanistic evidence to support and explain the findings of the RCTs. Testosterone is a rapid-onset arterial vasodilator within the coronary circulation and other vascular beds including the pulmonary vasculature and can reduce the overall peripheral systemic vascular resistance. Evidence has demonstrated that testosterone mediates this effect on vascular reactivity through calcium channel blockade (L-calcium channel) and stimulates potassium channel opening by direct nongenomic mechanisms. Testosterone also stimulates repolarization of cardiac myocytes by stimulating the ultra-rapid potassium channel-operated current. Testosterone improves cardiac output, functional exercise capacity, VO2max and vagally mediated arterial baroreceptor cardiac reflex sensitivity in CHF, and other mechanisms. Independent of the benefit of testosterone on cardiac function, testosterone substitution may also increase skeletal muscle glucose metabolism and enhance muscular strength, both factors that could contribute to the improvement in functional exercise capacity may include improved glucose metabolism and muscle strength. Testosterone improves metabolic CV risk factors including body composition, insulin resistance, and hypercholesterolemia by improving both glucose utilization and lipid metabolism by a combination of genomic and nongenomic actions of glucose uptake and utilization expression of the insulin receptor, glucose transporters, and expression on regulatory enzymes of key metabolic pathways. The effect on high-density lipoprotein-cholesterol (HDL-C) differs between studies in that it has been found to fall, rise, or have no change in levels. Testosterone replacement can suppress the levels of circulating pro-inflammatory cytokines and stimulate the production of interleukin-10 (IL-10) which has anti-inflammatory and anti-atherogenic actions in men with CVD. No effect on C-reactive protein has been detected. No adverse effects on clotting factors have been detected. RCTs have not clearly demonstrated any significant evidence that testosterone improves or adversely affects the surrogate markers of atherosclerosis such as reduction in carotid intima thickness or coronary calcium deposition. Any effect of testosterone on prevention or amelioration of atherosclerosis is likely to occur over years as shown in statin therapy trials and not months as used in testosterone RCTs. The weight of evidence from long-term epidemiological studies supports a protective effect as evidenced by a reduction in major adverse CV events (MACEs) and mortality in studies which have treated men with testosterone deficiency. No RCT where testosterone has been replaced to the normal healthy range has reported a significant benefit or adverse effect on MACE nor has any recent meta-analysis.

Effect of preinfarction angina on primary percutaneous coronary intervention outcomes

Background: Preinfarction angina has been recognized as a surrogate for preconditioning episodes. This study was designed to evaluate the cardiovascular effects of preinfarction anginal episodes among acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI). Materials and Methods: Of 520 patients who had undergone primary PCI, 393 patients were finally included in a prospective cohort study. Standard primary PCI procedure according to the latest guidelines was performed. The patients were divided into three groups based on previous symptoms as follows: asymptomatic (Group A), chronic stable angina (Group B) and unstable angina (Group C). Results: A total of 393 patients were evaluated. 185 (47.1%) patients were described as asymptomatic, 48 (12.2%) had stable angina and 160 (40.7%) were categorized as unstable angina. There was no significant difference among the study groups regarding pre- and post-PCI thrombolysis in myocardial infarction flow grade (P = 0.81). Median of peak post-PCI creatine-kinase-muscle/brain level of Group A (asymptomatic) was 250.5 (115.5–389), and it was significantly higher than Group C (176 [60.00–313.50]) (P = 0.03). Q wave formation was observed in 142 (88.75%), 31 (64.5%), and 96 (52.0%) patients of Group A, B, and C patients, respectively, which was significantly higher in asymptomatic patients (P = 0.002). There was no significant difference among the three groups regarding in-hospital and 6-month mortality (P = 0.36, 0.06, respectively). The composite endpoint of 6-month mortality, acute coronary events, cerebrovascular accidents, and target vessel revascularization was not significantly different between the three groups (P = 0.11). Conclusion: Preinfarction angina among AMI patients undergoing primary PCI seems to have a limited beneficial effect on infarct size, and this benefit was not translated to any clinical benefit.

A Cure of Coronary Artery Disease by Removing Atheromatous Plaques from Coronary Arteries in a Diabetic Patient

Objective: A cure for coronary artery disease is desperately needed as more people die of this disease. The coronary disease can be cured by removal of all atheromatous plaques by pharmacological intervention. This pharmacological treatment can also prevent acute myocardial infarction, unstable angina, chronic stable angina, CABG, PTCA and cardiac death. Case presentation: The patient is 75 years old, who had CABG and PTCA and suffered from daily chest pain which was relieved with nitroglycerin. Also had pain in both upper arms and both forearm several hours a day and this arm pain did not respond to nitroglycerin. She suffered with coughing wheezing and shortness of breath. No treatment helped her. Chest X-Ray showed cardiomegaly. EKG showed right bundle branch block. The coronary angiogram of 2013 showed advanced obstructive disease involving LAD and left circumflex artery with disease of the grafts. The right coronary artery was completely blocked with partially blocked graft. The patient was given standard treatment of coronary artery disease and for other conditions she suffered. The medications given for the removal of atheroma from coronary arteries were Carvedilol, Metformin, statin and Evolocumab. The patient was symptom free in 3 months. A repeat coronary angiogram in 2018 showed that LAD, left circumflex and right coronary arteries and their branches had no disease and no obstructive lesion. The graft to right to the right coronary artery was open and other grafts remained unchanged. Conclusions: 1) The atherosclerotic coronary artery disease can be cured. 2) Primary and secondary prevention of coronary artery disease can be achieved. 3) Intractable angina can be cured. 4) Stroke and TIA can be prevented. 5) Totally occluded coronary arteries can be opened.

Nicorandil and Long-acting Nitrates: Vasodilator Therapies for the Management of Chronic Stable Angina Pectoris.

Nicorandil and long-acting nitrates are vasodilatory drugs used commonly in the management of chronic stable angina pectoris. Both nicorandil and long-acting nitrates exert anti-angina properties via activation of nitric oxide (NO) signalling pathways, triggering vascular smooth muscle cell relaxation. Nicorandil has additional actions as an arterial K+ ATP channel agonist, resulting in more "balanced" arterial and venous vasodilatation than nitrates. Ultimately, these drugs prevent angina symptoms through reductions in preload and diastolic wall tension and, to a lesser extent, epicardial coronary artery dilatation and lowering of systemic blood pressure. While there is some evidence to suggest a modest reduction in cardiovascular events among patients with stable angina treated with nicorandil compared to placebo, this prognostic benefit has yet to be proven conclusively. In contrast, there is emerging evidence to suggest that chronic use of long-acting nitrates might cause endothelial dysfunction and increased cardiovascular risk in some patients.

Trimetazidine and Other Metabolic Modifiers.

Treatment goals for people with chronic angina should focus on the relief of symptoms and improving mortality rates so the patient can feel better and live longer. The traditional haemodynamic approach to ischaemic heart disease was based on the assumption that increasing oxygen supply and decreasing oxygen demand would improve symptoms. However, data from clinical trials, show that about one third of people continue to have angina despite a successful percutaneous coronary intervention and medical therapy. Moreover, several trials on chronic stable angina therapy and revascularisation have failed to show benefits in terms of primary outcome (survival, cardiovascular death, all-cause mortality), symptom relief or echocardiographic parameters. Failure to significantly improve quality of life and prognosis may be attributed in part to a limited understanding of ischaemic heart disease, by neglecting the fact that ischaemia is a metabolic disorder. Shifting cardiac metabolism from free fatty acids towards glucose is a promising approach for the treatment of patients with stable angina, independent of the underlying disease (macrovascular and/or microvascular disease). Cardiac metabolic modulators open the way to a greater understanding of ischaemic heart disease and its common clinical manifestations as an energetic disorder rather than an imbalance between the demand and supply of oxygen and metabolites.

The Pharmacological and Clinical Evidences of a Multi-herbal Drug Product - Dantonic (T89) Indicated for the Prevention and Treatment of Chronic Stable Angina - for FDA Registration

The Pharmacological and Clinical Evidences of a Multi-herbal Drug Product - Dantonic (T89) Indicated for the Prevention and Treatment of Chronic Stable Angina - for FDA Registration