Chronic Stable Angina Research Articles

A Systematic Review on the Economic Evaluations Evidence of Enhanced External Counter-Pulsation (EECP) for Managing Chronic Stable Angina.

Background: Chronic Stable Angina (CSA) does not respond to clinical interventions always. Therefore, enhanced external counter pulsation (EECP) has been approved by the Food and Administration Drug (FDA) as an effective technology. This study aimed to synthesize evidence on the economic evaluation of EECP in managing CSA through a systematic approach. Methods: In this systematic review study, PubMed/Medline, Cochrane Library, Web of Sciences, Scopus, National Institute for Health Research Journals Library, and the University of York Centre for Review and Dissemination (CRD) were searched. The targeted population was people who suffered from CSA, and the main therapeutic intervention was EECP. The comparators were not limited to any particular ones. Outcomes were changes in the Canadian Cardiovascular Society grading of angina pectoris, quality of life, and any other investigated relevant outcomes in the retrieved studies. The quality of studies was assessed through Philips et al and Joanna Briggs Institute Critical Appraisal tools. We synthesized data through a narrative approach. Results: We retrieved 7821 studies; among which 3 studies were included in the final phase. Two studies were systematic reviews and the Markov model economic evaluation. Another study was a partial economic evaluation. Conclusion: All studies only considered direct costs. EECP is a cost-effective technology in managing CSA, however, the sensitivity analysis of the studies showed the cost-effectiveness ratio is varied considerably and further studies are needed to extrapolate its economic value.

Physiological Significance of Myocardial Bridging by Fractional Flow Reserve—An Observational Study

Background Myocardial bridge (MB) is a portion of an epicardial coronary artery that takes an intramuscular course. The systolic compression of MB often gets carried over to early and mid-diastole, compromising coronary blood flow. In clinical practice, we encounter patients with angina, non-invasive evidence of ischemia, and a MB as the only relevant finding on angiography. In view of studies in support of decreased coronary flow reserve in MB, we assessed the physiological significance of MB by fractional flow reserve (FFR). Methods and Results We enrolled eight patients with chronic stable angina and positive noninvasive stress test, who had no significant CAD, and with evidence of MB in the left anterior descending artery. Mean age of population was 57.14 ± 6.25 years. Two (25%) were females and six (75%) were males. Four (50%) were smokers, five (62.5%) were diabetics, and two (25%) were hypertensives. Mean length of MB is 19.4 ± 5.04 mm. All underwent physiological assessment by FFR and the baseline, post nitroglycerin (NTG), and post adenosine readings were noted. Mean pre-NTG value, post-NTG, and post-adenosine were 0.974 ± 0.022, 0.96 ± 0.03, and 0.88 ± 0.042 (≤0.80 hemodynamically significant) respectively. Paired t-test showed significant reduction in FFR after NTG (p = 0.0452) and post-adenosine (p = 0.011) but all eight patients did not get significant FFR. Conclusion MB was found to be physiologically insignificant in our group of patients. But a statistical significant reduction of FFR in MB, post NTG and post adenosine, does impress on the fact that, an extensive study over a longer period of course, could throw light on this unsettled area of physiological significance and optimal therapeutic approach.

Risk factor profile, incidence, and relevance of Mehran risk score to predict contrast-induced nephropathy in patients undergoing percutaneous coronary intervention

Background: Contrast-induced nephropathy (CIN) is a grave but underdiagnosed complication of percutaneous coronary intervention (PCI) that is associated with increased in-hospital morbidity and mortality. Our aim was to study the incidence, risk factors of CIN, and applicability of Mehran risk score (MRS) in Indian population. Materials and Methods: A total number of 432 patients were enrolled in the study. Inclusion criteria were patients with acute coronary syndrome or chronic stable angina who underwent PCI. Baseline parameters of patients were noted and patients were followed for development of CIN. Results: The mean age of the study population was 57.2 + 10.43 years; males were 348 (80.6%) and females 84 (19.4%). Hypertension was present in 257 patients (59.5%), diabetes in 208 (48.1%), smoking in 208 (48.1%), anemia in 104 (24.1%), and heart failure in 95 (22%); the mean estimated glomerular filtration rate (eGFR) was 88.4 + 30.65 ml/min/1.73 m2 and the mean contrast volume usage was 122.8 + 41.9 ml. 64 patients (14.8%) developed CIN. On univariate analysis, age (P = 0.435), gender (0.125), hypertension (0.679), diabetes (0.177), and contrast volume (0.155) were not associated with the development of CIN, whereas smoking (0.021), hypotension (<0.001), heart failure (<0.001), anemia (0.001), and median eGFR (P < 0.001) were significantly associated with the development of CIN. However, on multivariate regression analysis, smoking was not associated with the development of CIN (P = 0.104). The incidence of CIN was 2.7-fold higher (odds ratio [OR]: 2.68, 95% confidence interval [CI]: 1.299–5.540, P= 0.008) in the intermediate group (MRS 6-10), 5.4-fold higher (OR: 5.403, 95% CI: 2.249–12.978, P < 0.001) in the high-risk group (MRS 11–15), and 51-fold higher (OR: 51.059, 95% CI: 18.195–143.278,P< 0.001) in the very high-risk groups (MRS >16) when compared to the low-risk group (MRS < 5). Dialysis was required only in 2 (3.1%) patients (P < 0.022). Conclusions: The overall incidence of CIN was 14.8%. The incidence of CIN in the very high-risk group (MRS >16) was substantially higher in our study (77.8%) as compared to the same group in Mehran study (57.3%).

Association of Severity of Coronary Artery Disease with Left Ventricular Diastolic Dysfunction among Diabetics with Stable Ischaemic Heart Disease: A Cross-sectional Study from Odisha, India

Introduction: Ischaemic Heart Disease (IHD) is one of the most common co-morbidity among Indian population, so is Diabetes Mellitus (DM). IHD is associated not only with systolic, but also with Diastolic Dysfunction (DDFx) of Left Ventricle (LV). However, there is scarcity of data correlating the severity of Coronary Artery Disease (CAD) with LV DDFx. Aim: To assess the severity of CAD in diabetic stable IHD patients with normal LV systolic function (LV Ejection fraction ≥50%) and it’s association with degree of DDFx. Materials and Methods: A prospective cross-sectional study was conducted over a period of one year, in a tertiary care hospital of Odisha, India among diabetic stable IHD patients. Grades of DDFx were assessed among the study population, using Transthoracic Echocardiography (TTE). Subsequently, severity of CAD was assessed, using invasive Coronary Angiography (CAG) using The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) score. Next, grades of DDFx were correlated with severity of IHD. Results: Among a total of 93 diabetic stable IHD patients with normal LV ejection fraction, 76.3% were males and the mean age was 60.7±8.9 years. Majority presented with chronic stable angina (59, 63.4%). Hypertension (50, 53.7%), followed by dyslipidaemia (36, 38.7%) and renal dysfunction (19, 20.4%) were the most common co-morbidities. Majority of patients had grade I (39.8%), followed by grade II (17.2%), and grade III (9.7%) DDFx. On invasive CAG, 39.8% had a SYNTAX score of ≤ 22, 36.6% had a score of 23-32, and 23.6% had a score of ≥33. Grades of DDFx were found to be significantly higher among the patients with greater SYNTAX score. Conclusion: Among diabetic stable IHD patients, greater the severity of CAD on CAG, higher were the grades of DDFx

Evaluation of Asymptomatic Carotid Artery Stenosis Prior to Coronary Artery Bypass Grafting - A Prospective Observational Study in North Indian Population.

Background:Carotid artery stenosis (CAS) is an established risk factor for peri-operative neurological complications in patients following coronary artery bypass grafting (CABG). However, routine pre-surgical screening for CAS is still a matter of debate. This study was conducted to study the prevalence of asymptomatic carotid artery disease in patients undergoing CABG and to determine the predictors of significant carotid stenosis in them.Methods:In this prospective observational study, 112 patients, who were planned for CABG, were enrolled, and their demographic details, risk factor profile, and coronary angiogram parameters were analyzed.Results:Carotid stenosis was observed in 75.0% of the study population with 11.6% having unilateral and 63.4% having bilateral carotid stenosis. A total of 56.2% of the patients had mild, 14.3% had moderate, and 4.5% had severe carotid stenosis. The presence of significant carotid stenosis showed a correlation with chronic stable angina (P = 0.009), significant left main (LM) disease (P = 0.001), chronic total occlusion (P = 0.043), and coronary vessel calcification (P = 0.004). Multivariate analysis of all the predictor variables in a regression model showed that significant LM disease (Odds ratio (OR):6.5, P = 0.002) and coronary artery calcification (OR: 4.3, P = 0.024) were the only independent predictors of significant CAS in the study population.Conclusion:The presence of significant carotid vessel stenosis in patients undergoing CABG in the Indian population has a stronger association with the chronicity of the coronary artery disease rather than the coronary atheroma load (as determined by the modified Gensini score). The presence of significant LM disease and coronary artery calcification may be useful in detecting high-risk patients for significant CAS during the pre-surgical workup.

Atherogenic index of plasma: A valuable novel index to distinguish patients with unstable atherogenic plaques.

Background:Plaque instability is a leading cause of morbidity and mortality in coronary artery disease (CAD) patients. Numerous efforts have been made to figure out and manage unstable plaques prior to major cardiovascular events incidence. The current study aims to assess the values of the atherogenic index of plasma (AIP) to detect unstable plaques.Materials and Methods:The current case-control study was conducted on 435 patients who underwent percutaneous coronary intervention due to chronic stable angina (stable plaques, n = 145) or acute coronary syndrome (unstable plaques, n = 290). The demographic, comorbidities, chronic medications, biochemical and hematological characteristics of the patients were entered into the study checklist. The baseline AIP was measured according to the formula of triglycerides/high-density lipoprotein logarithm. Binary logistic regression was applied to investigate the standalone association of AIP with plaque instability. Receiver operating curve (ROC) was depicted to determine a cut-off, specificity, and sensitivity of AIP in unstable plaques diagnosis.Results:AIP was an independent predictor for atherogenic plaque unstability in both crude (odds ratio [OR]: 3.677, 95% confidence interval [CI]: 1.521–8.890; P = 0.004) and full-adjusted models (OR: 15, 95% CI: 2.77–81.157; P = 0.002). According to ROC curve, at cut-point level of 0.62, AIP had sensitivity and specificity of 89.70% and 34% to detect unstable plaques, respectively (area under the curve: 0.648, 95% CI: 0.601–0.692, P < 0.001).Conclusion:According to this study, at the threshold of 0.62, AIP as an independent biomarker associated with plaque instability can be considered a screening tool for patients at increased risk for adverse events due to unstable atherosclerotic plaques.

Complete revascularization optimizes patient outcomes in multivessel coronary artery disease: Data from the e-Ultimaster registry.

ObjectivesThe aim of this analysis was to assess the effect of the coronary revascularization strategy during index admission on clinical outcomes among patients undergoing percutaneous coronary intervention (PCI) with multivessel coronary artery disease (MVD).BackgroundThe value of complete revascularization (CR) over incomplete revascularization (IR) in MVD patients is not fully established.MethodsPatients with MVD defined as ≥2 major epicardial vessels with ≥50% stenosis were selected from the observational all‐comer e‐Ultimaster registry. Patients were treated with a sirolimus‐eluting thin‐strut coronary stent. Completeness of revascularization was physician assessed at the index procedure or an eventually staged procedure during the index hospitalization. Outcomes measures at 1 year were target lesion failure (TLF) (composite of cardiac death, target vessel‐related myocardial infarction [MI], and clinically driven target lesion revascularization [TLR]), and patient‐oriented composite endpoint (POCE) (all‐cause mortality, MI, or revascularization). The inverse probability of treatment weights (IPTW) methodology was used to perform a matched analysis.ResultsThe registry recruited 37,198 patients of whom 15,441 (41.5%) had MVD. CR on hospital discharge was achieved in 7413 (48.0%) patients and IR in 8028 (52.0%) patients. Mean age was 64.6 ± 11.1 versus 65.7 ± 11.0 years (p < 0.01), male gender 77.9% and 77.3% (p = 0.41) and diabetes 31.3% versus 33.4% (p = 0.01) for CR and IR, respectively. Chronic stable angina patients more commonly underwent CR (47.6% vs. 36.8%, p < 0.01). After propensity weighted analysis, 90.5% of CR patients were angina‐free at 1 year compared with 87.5% of IR patients (p < 0.01). TLF (3.3% vs. 4.4%; p < 0.01), POCE (6.8% vs. 10.8%; p < .01), and all‐cause mortality (2.3% vs. 3.1%; p < .01) were all lower in CR patients.ConclusionsA physician‐directed use of a CR strategy utilizing sirolimus‐eluting thin‐strut stent results in optimized clinical outcomes and less angina in an all‐comer population. Our findings suggest that a CR should be aimed for.

695 Upregulated monocyte expression of PLIN2 is associated with plaque instability in coronary artery disease

Abstract Aims Perilipin 2 (PLIN2), a protein associated with intracellular lipid droplets (LDs), is involved in lipid metabolism of macrophages resident in atherosclerotic plaques and its up-regulation leads to LDs accumulation. LDs enlargement results in the macrophage transformation into foam cells, a key step for the onset of atherosclerosis. In the present study, we investigated the role of PLIN2 and its regulation mechanisms in atherosclerosis and plaque instability in patients with a diagnosis of ST-elevation myocardial infarction (STEMI) and stable chronic angina (SA). Methods and results We enrolled 120 patients with a diagnosis of STEMI and 42 SA patients with symptoms of stable effort angina lasting more than 12 months. Peripheral blood mononuclear cells (PBMCs) were isolated from EDTA whole blood samples through standard gradient centrifugation over Ficoll-Hypaque. Monocytes were purified through indirect magnetic labelling of PBMCs. PLIN2 mRNA expression was investigated by Real Time-PCR and PLIN2 protein level was analysed in CD14+ monocytes by flow cytometry. Proteasome activity was assayed using AMC-tagged peptide substrate (Succ-LLVY-AMC), which releases free highly fluorescent AMC (Ex/Em 350/440 nm) in the presence of proteolytic activity. In CD14+ monocyte, PLIN2 protein expression was significantly increased in STEMI as compared to SA patients (P &amp;lt; 0.001), while PLIN2 mRNA level was not different in the two groups (P = n.s.). Despite proteasome activity was higher in STEMI as compared to SA patients (P &amp;lt; 0.001), significant inverse correlations were evident between PLIN2 levels and proteasome activity in the two groups (P = 0.05). Conclusions CD14+ monocyte PLIN2 protein expression was higher in STEMI as compared to SA patients suggesting an involvement in plaque instability. Despite proteasome activity was higher in STEMI patients, probably due to the elevated inflammatory burden, PLIN2 could escape proteasome degradation in a more efficient manner in STEMI as compared to SA patients.

Ranolazine: a better understanding of its pathophysiology and patient profile to guide treatment of chronic stable angina.

Chronic stable angina pectoris, the most prevalent symptomatic manifestation of coronary artery disease, greatly impairs quality of life and is associated with an increased risk for adverse cardiovascular outcomes. Better understanding of the pathophysiologic mechanisms of myocardial ischemia permitted new therapeutic strategies to optimize the management of angina patients. Ideally, antianginal drug treatment should be tailored to individual patient's profile and chosen according to the pathophysiology, hemodynamic profile, adverse effects, potential drug interactions and comorbidities. In this respect, and because of its peculiar mechanism of action, ranolazine represents an alternative therapeutic approach in patients with chronic stable angina and may be considered the first choice in presenceof comorbiditiesthat difficult the use of traditional therapies.

Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies.

Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.

Correlation of Triglyceride with Coronary Artery Disease Severity in Pre-Diabetic Chronic Stable Angina Patients

Background: Individuals with prediabetes have multiple disturbances in lipoprotein metabolism resulting from multiple combinations of insulin deficiency, insulin resistance and hyperglycemia. Dyslipidemia is the commonest complication of prediabetes and diabetes, and it predispose to premature atherosclerosis causing cardiovascular complication. The aim of this study was to assess correlation of triglyceride (TG) with coronary artery disease (CAD) severity in pre-diabetic chronic stable angina patients.&#x0D; Methods: Our cross-sectional observational study was conducted on 100 pre-diabetic patients (HbA1c 5.7% to 6.4%) with different levels of TG and stable CAD, referred to Tanta university hospitals. Each patient had been subjected to adequate history taking, complete clinical examination and laboratory investigations and electrocardiogram with transthoracic echocardiography. SYNTAX score was calculated.&#x0D; Results: There were significant positive correlations between TG and LDL, ratio and TLC respectively while there was a significant negative correlation between TG and HDL. There was significant positive correlation between SYNTAX and LDL, ratio and urea respectively while there was high significant negative correlation between TG and HDL. TG level was significantly higher in male than female (p= 0.028). There was no significant difference in SYNTAX regarding gender. For the multivariate analysis, only LDL was a significant independent predictor for CAD.&#x0D; Conclusions: There was a positive correlation between the TG and the severity of coronary lesions in pre-diabetic stable angina pectoris patients.

Vascular dysfunction and its recovery after transradial coronary angioplasty- A serial observational study

ObjectiveTo serially evaluate the effect of trans-radial coronary angioplasty (TRA) on the vascular function of radial artery (RA) and upstream brachial artery (BA) and to find out the relative contribution of endothelial dependent flow-mediated vasodilatation (FMD) and endothelial independent nitrate mediated dilatation (NMD). MethodsForty patients of chronic stable angina with successful TRA were studied. FMD and NMD of bilateral RA and BA were measured with high-resolution ultrasound, before and at 24 h and at 3 months, after catheterization. ResultsFMD as well as NMD were significantly decreased in right RA (16.3 ± 3.6% to 5.7 ± 1.8%; p = 0.001, and 24.1 ± 5.3% to 9.7 ± 2.8%; p = 0.001, respectively) as well as in upstream BA (17.0 ± 1.6% to 9.4 ± 0.5%; p = 0.001,and 26.5 ± 6.8% to 20.5 ± 3.7%; p = 0.001, respectively) at 24 h. FMD/NMD ratio was also decreased in RA (70 ± 10% to 60 ± 10%; p = 0.04) and as well as in BA (70 ± 20% to 50 ± 10%; p = 0.03). The endothelial dysfunctions returned to normal at 3 months. Control arm did not show any change in vascular function at any point of time. Radial artery diameter/sheath ratio <1 and catheter exchanges >2 were the independent predictors for >50% decrease in FMD. ConclusionsTRA results in reversible depression in FMD as well as NMD in the radial artery as well as upstream brachial artery. These vascular dysfunctions are limited to the catheterized arm only and return to normal after 3 months.

A nationwide questionnaire-based survey on practice patterns and management of chronic stable angina with a controlled release formulation of trimetazidine

Background: There is lack of real-world evidence on various aspects of chronic stable angina (CSA). Hence, a questionnaire-based survey was conducted to garner real-world data about the prevalence of CSA among Indian patients; the associated comorbidities among these patients; management practices for CSA in India; and factors affecting compliance in patients with CSA with a special focus on day and night pack for trimetazidine controlled release (CR) 35 mg BD tablets.Methods: In all, 100 health care practitioners (HCPs) who each observed 15 patients with CSA in their clinical practice participated in this quantitative, cross-sectional, questionnaire-based study. The data were collected using a structured questionnaire with 30 questions grouped into 5 sections. Data were analyzed using percentages.Results: The results from the survey showed that 52.7% HCPs had observed 31-50% of angina patients with diabetes mellitus as comorbidity. As per the questionnaire survey, 77.4% HCPs preferred trimetazidine as a second-line agent when an angina patient was not responding to beta-blockers, calcium channel blockers (CCBs), and nitrates. Furthermore, 30.1% of HCPs preferred trimetazidine CR 35 mg BD as it improved exercise tolerance as well. Results from the survey reported that 65.6% HCPs agreed with the statement that day and night packs of trimetazidine tablets help in improving patient compliance and adherence to therapy.Conclusions: Trimetazidine CR 35 mg BD appears to have a safety profile suitable for various conditions and for patients with multiple comorbidities. Trimetazidine day and night packs of tablets help in improving patient compliance and adherence to therapy.

Elevated heart rate across cardiovascular continuum and its management

Elevated heart rate in both healthy individuals and patients with coronary artery disease (CAD), acute myocardial infarction (AMI) and heart failure poses a major risk factor for morbidity and mortality. This fact has further been supported by several studies pointing out to elevated resting heart rate as an important marker for this catastrophe necessitating a prompt therapeutic action plan, consisting of early detection and treatment of the risk factors, to achieve ideal heart rates (approximately 60 beats/minute) in patients which could stop or prevent the progression of the cardiovascular disease (CVD) continuum. Lowering heart rate by therapeutic interventions has shown favorable results, but most of the data so far is retrospective and limited to AMI and heart failure with beta-blocker treatment. Addition of newer drugs into the cardiac armamentarium, like ivabradine, a sinus node inhibitor acting by selective heart rate reduction, has shown several beneficial effects in a variety of conditions spanning from stable angina to heart failure. A consensus meeting was held at the national level wherein experts from various parts of the country discussed and reviewed the importance of heart rate lowering across CV continuum and addition of ivabradine for patients with chronic heart failure and chronic stable angina.

Evaluation of management strategies in patients with coronary ectasia: a retrospective cohort study

Abstract Background/Introduction Since patients with coronary ectasia have an increased risk of developing myocardial infarction and cardiovascular death, these patients could benefit from a more intensive treatment. Unfortunately, the evidence regarding outcomes with different management strategies is limited, especially with direct oral anticoagulants (DOAC). Purpose To compare clinical outcomes in patients with coronary ectasia based on the selected/chosen treatment strategy. Methods We conducted a retrospective cohort study in patients diagnosed with coronary artery ectasia. They were divided into 3 different groups based on the treatment they received at discharge and we evaluated the main cardiovascular outcomes at one-year follow-up. Results Between 2016 and 2019, 7,579 angiographies were performed, in which 510 patients with coronary ectasia were found (prevalence of 6.72%). Of these patients, 43.9% (n=224) had the diagnosis of STEMI, 21% NSTEMI (n=107), 5.1% unstable angina (n=26), 18.6% chronic stable angina (n=95) and other 11.4% (n=58). The angiographic distribution of the lesions was as follows: left main coronary artery 25.1%, Left descending coronary artery 62.7%, circumflex artery 52.1%, right coronary artery 79.2%. It was possible to obtain the follow-up of 363 patients (71.2%) because 25 died during their hospitalization and data of 122 were not available at the time of analysis. Three groups were formed based on the treatment: (1) Dual Antiplatelet Therapy (DAPT) in 47% (n=174); (2) DAPT + Vitamin K Antagonist (VKA) in 8.5% (n=31); (3) DAPT + DOAC in 6.6% (n=24). The overall MACE rate at 1-year of follow-up was 6.6% (n=15): 11 patients in the DAPT group (6.3%), 1 patient in the DAPT + VKA group (3.2%), and 3 patients in the DAPT + DOAC group (12.5%). During this period, 3 patients died from cardiovascular causes, all of them in the DAPT group. Myocardial infarction occurred in 12 patients, 8 in the DAPT group (4.2%), 1 in the DAPT + VKA group (3.2%) and 3 in the DAPT + DOAC group (12.5%). Stroke occurred in 2 patients: 1 patient in the DAPT group (0.5%) and 1 patient in the DAPT + DOAC group, 4.1% None of these findings were statistically significant. One-year occurrence of bleeding events was also evaluated: 23 patients presented a bleeding event, 14 in the DAPT group (8%), 7 in the DAPT + VKA group (22.5%) and 2 in the DAPT + DOAC group (8.3%); p=0.010. Conclusion(s) Our findings suggest that there is no statistically significant difference in the incidence of thrombotic complications, when comparing the treatment options. Patients using the combination of DAPT+VKA have a higher incidence of bleeding. Funding Acknowledgement Type of funding sources: None.

Intravascular ultrasound guidance to minimize the use of contrast in percutaneous coronary interventions in diabetic patients with chronic stable angina

Abstract Objective To evaluate the impact of Intravascular ultrasound guidance on the final volume of contrast agent utilized in diabetic patients undergoing PCI for chronic stable angina. Background To date, few approaches have been described to reduce the final dose of contrast agent in percutaneous coronary interventions (PCI). We hypothesized that intravascular ultrasound (IVUS) might serve as an adjuctive imaging tool in many steps during PCI, thereby reducing the use of iodine contrast. Methods A total of 100 Diabeic Egyptian patients were selected to angiography-guided PCI or IVUSguided PCI from June 2019 to January 2020 .The study type was case control and non consecutive . Both groups were treated according to a pre-defined meticulous procedural strategy. A written informed consent was taken from all patients.The primary endpoint was the total volume contrast agent used during PCI. Patients were followed clinically for an average of 6 months. Results The median total volume of contrast was 111.65 ml (interquartile range [IQR] 170.40 ± 52.91ml , range from 100 ml to 300 ml) in angiography-guided group vs. 56.99 ml (IQR 94.70 ± 19.28ml , range from 70 ml to 180 ml) in IVUS-guided group (p &amp;lt; 0.001).similary, the median total volume of contrast was 111.65 ml (interquartile range [IQR] 170.40 ± 52.91ml , range from 100 ml to 300 ml) in angiographyguided group vs. 56.99 ml (IQR 94.70 ± 19.28ml , range from 70 ml to 180 ml) in IVUS-guided group (p &amp;lt; 0.001).In-hospital and 6 month outcomes were not different between patients randomized to angiography-guided and IVUS-guided PCI according to : Death, Acute myocardial infarction, Unplanned revascularization, Stent thrombosis. Conclusions Thoughtful and extensive utilization of IVUS as the primary imaging tool to guide PCI is safe, and markedly reduces the volume of iodine contrast, compared to angiography alone guidance.

Through the heart and beyond: a review on ranolazine

Ranolazine derives from piperazine and has been approved as a drug for the therapy of chronic stable angina. It acts by selectively inhibiting the late sodium inward current. Moreover, ranolazine has other metabolic features which makes it effective in other diseases as well as coronary artery ones. In this paper I make an updated review of all possible therapeutic roles of ranolazine: through cardiology and beyond.

Frequency of High Neutrophil and Lymphocyte Ratio (NLR) Among NSTEMI/USA patients

Background: Neutrophil to lymphocyte ratio (NLR) is comparatively a new prognostic marker used in patients with chronic stable angina (CSA). NLR can help in predicting short and long term moralities in NSTEMI patients. Aim: To evaluate the frequency of high neutrophil and lymphocyte ratio among NSTEMI/USA patients and to compare frequency of mortality in patients of NSTEMI/USA having high NLR with those without high NLR. Study design&amp; duration: Descriptive, case series study from 25th November 2020 to 24th May 2021. Study settings: Department of Medicine and Cardiology, Fatima Memorial Hospital, Lahore. Methods: 185 patients having non ST elevation myocardial infarction (NSTEMI) and/or unstable angina (UA) having 30 to 70 years age and both males and females were included. Patients with sepsis having total Leucocyte count (TLC&gt;11,000/&lt;4000), history of surgery or on steroids in the past three months, history of hematological malignancy, late for fibrinolysis or those with contraindication to fibrinolysis were excluded were excluded. Demographic information (name, age, address, and education) was also noted. Results: Mean age of the participants was 57.99 ± 6.10 years while the age range was from 30 to 70 years. Most of patients 164 were included in the age group of 51 to 70 years. 110 (59.46%) patients were male and 75 (46.54%) of them were females. Frequency of neutrophil and lymphocyte ratio among NSTEMI/USA patients was found in 91 (49.19%) patients. My study has shown higher frequency of mortality in patients of NSTEMI/USA having high NLR 26 (28.57%) compared to normal NLR 06 (6.38%) with p value = 0.0001. Conclusion: Frequency of high neutrophil and lymphocyte ratio among NSTEMI/USA patients is very high with higher mortality in high Neutrophil-to-lymphocyte ratio group as compared to low NLR group. Keywords: Myocardial infarction, Non ST elevation, Neutrophil-to-lymphocyte ratio

Quality of Life Assessment in Trials of Revascularization for Chronic Stable Angina: Insights from ORBITA and the Implications of Blinding

The main aims of therapy in chronic stable angina are to reduce the risk of myocardial infarction and death and improve symptoms and quality of life (QoL). Unblinded trials have shown that revascularization does not reduce the risk of myocardial infarction or death but does appear to improve symptoms. However, symptoms are susceptible to the placebo effect which can bias therapies to appear more effective than they are. To assess the true physical impact of a treatment on symptoms, placebo-controlled trials with patients and medical and research teams blinded to treatment allocation are necessary. Symptoms and QoL can be reported directly by the patient or indirectly by the physician. Patient-reported outcome measures in angina trials can include angina frequency, frequency of nitrate use, exercise capacity, and questionnaires such as the Seattle Angina Questionnaire (SAQ) and the generic EuroQOL-5D-5L (EQ-5D-5L) QoL questionnaire. Physician-assessed outcome measures include Canadian Cardiovascular Society Class. The Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was the first blinded placebo-controlled study investigating the role of percutaneous coronary intervention (PCI) in chronic stable angina. The trial showed a smaller than expected and not statistically significant effect of placebo-controlled PCI on the primary endpoint of change in exercise time at 6 weeks follow-up in single-vessel coronary artery disease. There was also no significant placebo-controlled treatment effect of PCI for the prespecified secondary endpoints of SAQ or EQ-5D-5L, although PCI did result in 20% more patients becoming free from angina than placebo in a non-prespecified secondary analysis. ORBITA has demonstrated the need for symptomatic and QoL effects of PCI to be studied using placebo control. Here, we describe ways of measuring QoL, the impact of the unblinded and blinded trials to date, what we have learned from ORBITA, and what is next for this common and complex condition.

Transthoracic echocardiographic assessment of global left ventricular perfusion before and after percutaneous coronary intervention in patients with chronic stable angina

Transthoracic echocardiographic assessment of global left ventricular perfusion before and after percutaneous coronary intervention in patients with chronic stable angina