Management Of Stable Angina Research Articles

Debate. �Orbiting� around the management of stable angina. The clinician�s perspective

Debate. �Orbiting� around the management of stable angina. The clinician�s perspective

Debate. �Orbiting� around the management of stable angina. The interventional cardiologist�s perspective

Debate. �Orbiting� around the management of stable angina. The interventional cardiologist�s perspective

Nanostructured lipid carriers of ivabradine hydrochloride: Optimization, characterization and in-vivo estimation for management of stable angina

Stable angina (angina pectoris) is a type of chest pain that happens when the heart muscle needs more oxygen than usual but it's not getting it at that moment because of heart disease. The drawback of the marketed formulation is required repeated administration of the drug due to low bioavailability. A recently licenced medication called ivabradine hydrochloride (IVB) is used to treat stable angina and signs of heart failure. Technical problems in the approved IBH tablets include a two-hour half-life, erratic systemic absorption, and a high rate of first-pass metabolism (>50%). We therefore created a distinctive and cutting-edge formulation of IVB using a nano formulation approach like nanostructured lipid carriers (NLCs). The response surface method with a three-level Box–Behnken design was used for the creation and improvement of IVB. The optimized formulation was proceeded for physicochemical characterizations like particle size, zeta potential, morphology (TEM and SEM), entrapment efficiency, in-vitro release, stability studies, compatibility study (DSC, FTIR and XRD), hemocompatibility study, ex-vivo permeability, and in-vivo angina study. As results, optimized formulation was found to be 114.45 ± 5.14 nm particle size with 83.45 ± 3.23% entrapment efficiency and biphasic release. The formulation showed spherical and compatible with excipients, no interaction was observed and hemocompatible. The IBH-NLCss showed more permeability (1.85 folds) as compared to the marketed dosage form. The in-vivo pharmacological activity was established in terms of decrease in severity and duration of ST-segment depression in vasopressin-induced angina model in experimental rats.

Management of Stable Angina in the Older Adult Population.

As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.

Management of Stable Angina: A Treatment Strategy Mnemonic

Nurse practitioners are well-positioned to diagnose and manage stable angina pectoris by implementing guideline-driven medical interventions. This report presents a mnemonic based on current guidelines to support the nurse practitioner by effectively recalling and using evidence-based treatment plans in clinical practice.

Coronary Wave Intensity Analysis as an Invasive and Vessel-Specific Index of Myocardial Viability.

Coronary angiography and viability testing are the cornerstones of diagnosing and managing ischemic cardiomyopathy. At present, no single test serves both needs. Coronary wave intensity analysis interrogates both contractility and microvascular physiology of the subtended myocardium and therefore has the potential to fulfil the goal of completely assessing coronary physiology and myocardial viability in a single procedure. We hypothesized that coronary wave intensity analysis measured during coronary angiography would predict viability with a similar accuracy to late-gadolinium-enhanced cardiac magnetic resonance imaging. Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. Coronary wave intensity analysis was assessed during cardiac catheterization at rest, during adenosine-induced hyperemia, and during low-dose dobutamine stress using a dual pressure-Doppler sensing coronary guidewire. Scar burden was assessed with cardiac magnetic resonance imaging. Regional left ventricular function was assessed at baseline and 6-month follow-up after optimization of medical-therapy±revascularization, using transthoracic echocardiography. The primary outcome was myocardial viability, determined by the retrospective observation of functional recovery. Forty participants underwent baseline physiology, cardiac magnetic resonance imaging, and echocardiography, and 30 had echocardiography at 6 months; 21/42 territories were viable on follow-up echocardiography. Resting backward compression wave energy was significantly greater in viable than in nonviable territories (-5240±3772 versus -1873±1605 W m-2 s-1, P<0.001), and had comparable accuracy to cardiac magnetic resonance imaging for predicting viability (area under the curve 0.812 versus 0.757, P=0.649); a threshold of -2500 W m-2 s-1 had 86% sensitivity and 76% specificity. Backward compression wave energy has accuracy similar to that of late-gadolinium-enhanced cardiac magnetic resonance imaging in the prediction of viability. Coronary wave intensity analysis has the potential to streamline the management of ischemic cardiomyopathy, in a manner analogous to the effect of fractional flow reserve on the management of stable angina.

Coronary wave energy to predict functional recovery in patients with ischemic left ventricular dysfunction

Abstract Background Invasive coronary angiography and non-invasive viability testing are the cornerstones of diagnosing and managing ischemic left ventricular dysfunction. At present there is no single test which serves both needs but, if developed, could revolutionise investigation of this condition. Coronary wave intensity analysis (cWIA) interrogates both contractility and microvascular physiology of the subtended myocardium [1,2] and therefore has the potential to fulfil this goal. Objectives We hypothesized that cWIA measured during coronary angiography would predict functional recovery with a similar accuracy to late gadolinium enhanced cardiac magnetic resonance imaging (LGE-CMR). Methods Patients with a left ventricular ejection fraction ≤40% and extensive coronary disease were enrolled. cWIA, fractional flow reserve and microvascular resistance were assessed with a simultaneous coronary Doppler and pressure-sensing guidewire during cardiac catheterization at rest, during hyperaemia and during low-dose dobutamine stress. Viability was assessed using LGE-CMR. Regional left ventricular function was assessed at baseline and 6-month follow up after optimization of medical therapy +/− revascularization, using transthoracic echocardiography. The primary outcome was regional functional recovery. Results Forty participants underwent baseline physiology, LGE-CMR and thirty had echocardiography at baseline and 6 months; 21/42 territories demonstrated functional recovery. Resting backward compression wave energy was significantly greater in recovering than non-recovering territories (−5240±3772 vs. −1873±1605 W m–2 s–1, p=0.099, Figure 1), and had comparable diagnostic accuracy to CMR (area under the curve 0.812 vs. 0.757, p=0.649, Figure 2); a threshold of −2500 W mm–2 s–1 had 86% sensitivity and 76% specificity at predicting recovery. Backward expansion wave energy did not predict recovery. FFR was numerically higher in recovering territories (0.81±0.17 vs. 0.71±0.16, p=0.058), whilst hyperaemic microvascular resistance did not differentiate recovering from non-recovering territories (1.97±0.73 vs. 2.29±1.00, p=0.287). The likelihood of functional recovery was similar in revascularised and non-revascularised territories (15/29 vs. 6/13 respectively, p=0.739). Low-dose dobutamine stress increased the energy of all waves, but did not improve the accuracy of cWIA in predicting recovery. In a regression model, resting backward compression wave energy and optimization of medical therapy predicted functional recovery; fractional flow reserve and hyperemic microvascular resistance did not. Conclusions Backward compression wave energy has similar accuracy to LGE-CMR in the prediction of functional recovery. cWIA has the potential to revolutionise the management of ischaemic left ventricular dysfunction, in a manner analogous to the effect of fractional flow reserve on the management of stable angina. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The British Heart Foundation Clinical Research Training Fellowship

The impact of cardiopulmonary hemodynamic factors in volumetry for pulmonary nodule management

BackgroundThe acceptance of coronary CT angiogram (CCTA) scans in the management of stable angina has led to an exponential increase in studies performed and reported incidental findings, including pulmonary nodules (PN). Using low-dose CT scans, volumetry tools are used in growth assessment and risk stratification of PN between 5 and 8 mm in diameter. Volumetry of PN could also benefit from the increased temporal resolution of CCTA scans, potentially expediting clinical decisions when an incidental PN is first detected on a CCTA scan, and allow for better resource management and planning in a Radiology department. This study aims to investigate how cardiopulmonary hemodynamic factors impact the volumetry of PN using CCTA scans. These factors include the cardiac phase, vascular distance from the main pulmonary artery (MPA) to the nodule, difference of the MPA diameter between systole and diastole, nodule location, and cardiomegaly presence.Materials and methodsTwo readers reviewed all CCTA scans performed from 2016 to 2019 in a tertiary hospital and detected PN measuring between 5 and 8 mm in diameter. Each observer measured each nodule using two different software packages and in systole and diastole. A multiple linear regression model was applied, and inter-observer and inter-software agreement were assessed using intraclass correlation.ResultsA total of 195 nodules from 107 patients were included in this retrospective, cross-sectional and observational study. The regression model identified the vascular distance (p < 0.001), the difference of the MPA diameter between systole and diastole (p < 0.001), and the location within the lower or posterior thirds of the field of view (p < 0.001 each) as affecting the volume measurement. The cardiac phase was not significant in the model. There was a very high inter-observer agreement but no reasonable inter-software agreement between measurements.ConclusionsPN volumetry using CCTA scans seems to be sensitive to cardiopulmonary hemodynamic changes independently of the cardiac phase. These might also be relevant to non-gated scans, such as during PN follow-up. The cardiopulmonary hemodynamic changes are a new limiting factor to PN volumetry. In addition, when a patient experiences an acute or deteriorating cardiopulmonary disease during PN follow-up, these hemodynamic changes could affect the PN growth estimation.

Diagnosis and management of stable angina in primary care

Angina is the main symptom of myocardial ischaemia, and the most common cause of angina is coronary artery disease. The presence of angina is therefore associated with an increased risk of subsequent cardiac events and mortality that can be reduced by appropriate medical treatment or surgical intervention. GPs should ensure that patients presenting with symptoms consistent with angina are rapidly assessed. This article gives a framework for managing stable angina in primary care.

Diagnosis and management of stable angina

Diagnosis and management of stable angina

Program «Smart ECG – ranolazin» - own experience and world approach

Purpose - comprehensive analysis of the world approach of the use of ranolazine in various clinical trials and the introduction of the program "Smart ECG" to assess the effectiveness of ranolazine.Matherial and methods. Evaluation of European guidelines, analysis of global randomized clinical trials of the ranolazine use, presentation of our own trial: we examined 40 patients with Q wave myocardial infarction (STEMI), were instituted basic therapy according to the modern recommendations which contained interventional treatment with restoration of patency of a heart attack-conditioned coronary artery, double antiplatelet therapy, statins, β-adrenergic blocker, angiotensin-converting enzyme inhibitors, aldosterone antagonists with addition of ranolazine (group I, 30 patients diagnosed STEMI), control - group II, 10 patients with STEMI, who received basic therapy without addition of ranolazine. Results. Analysis of clinical trials (CARISA, MARISA, ERICA, TERISA, MERLIN-TIMI, RIVER-PCI, RIMINI-TRIAL) proved the effectiveness of ranolazine as an antianginal and anti-ischemic drugs. The use of own program «Smart ECG» demonstrates the positive effect of ranolazine on STEMI and requires further implementation.Conclusion. In the European Society of Cardiology guidelines of the management of stable angina pectoris, ranolazine is given a class IIa (level of evidence B) recommendation as a second-line treatment to reduce angina frequency and improve exercise tolerance in subjects who cannot tolerate, have contraindications to, or whose symptoms are not adequately controlled by β- adrenergic blockers, calcium channel blockers and long-acting nitrates. In subjects with baseline low heart rate and low blood pressure, ranolazine may be considered as a first-line drug to reduce angina frequency and improve exercise tolerance - class IIa (level of evidence C) recommendation. Own study, which partially reflects the global approach according to the analyzed clinical studies, demonstrates the positive effect of ranolazine for patients with STEMI - analogue scale EQ–VAS indicates a positive effect, positive influence on the markers of electrical myocardial instability: decreasing of the probability of cases of SDNN decrease, depression of QT and maybe increase of ratio of maximum velocity for differentiated T wave.

Conservative Approach Might Be the Strategy by Default in Stable Angina Patients: A Case Report

Management of stable angina is still a matter of debate. Whether a conservative or invasive approach is better remains unclear. Even though recent large-scale randomized trials depict the conservative strategy as safe and efficient. In this report, we present a case of a 53-year-old male patient with cardiovascular risk factors of hypertension and hypercholesterolemia. He complained about typical chest pain at exertion. The coronary angiogram (CA) revealed severe stenosis of the proximal left anterior descending artery (LAD) ostium. After heart team discussion, coronary artery bypass graft (CABG) was advocated. However, due to a lack of means, the CABG was postponed. Meanwhile, he was managed with guideline-based medical therapy. In addition, he exercised regularly and adopted a healthy diet. Evolution was favorable with excellent symptoms control. A regular follow-up was organized with his cardiologist. A new CA before an eventual CABG six years later showed a significant plaque volume regression of the proximal LAD. We decided to continue conservative management. The stress echocardiogram to assess symptoms and exercise tolerance was normal. Our patient was sent to surgery on top of optimal medical therapy even though angioplasty was a good indication and was feasible. However, while he was struggling to afford the CABG procedure, he adopted a very healthy lifestyle along with medical therapy. Six years later, the result of that approach was without appeal, suggesting and reinforcing the conservative management of stable heart disease over invasive strategy. The recent ISCHEMIA trial is a major argument supporting that approach.

Rational design and in-vivo estimation of Ivabradine Hydrochloride loaded nanoparticles for management of stable angina

Stable angina or angina pectoris is referred to as uneasiness/pain in the chest, resulting from coronary heart disease (CHD). Ivabradine Hydrochloride (IBH) is a recently approved drug to manage stable angina and heart failure symptoms. The approved IBH tablets exhibit some technical shortcomings i.e. short half-life (2 h), variable systemic absorption, and high first-pass metabolism (>50%). Therefore, utilizing a nanoformulation technique, we have designed a differentiated and innovative formulation of IBH. The IBH loaded polymeric nanoparticles (IBH-PNPs) are being developed for per-oral delivery by double emulsion method, using Poly lactic-co-glycolic acid (PLGA) as polymer, and d-α-tocopherol polyethylene glycol 1000 succinate (TPGS) as a stabilizer. The pre-formulation studies performed are UV spectroscopy, FT-IR, and X-ray diffraction. The Box-Behnken design was exploited for formulation optimization. The optimized formulation was characterized for its particle size, zeta potential, morphology, entrapment efficiency, in-vitro release, stability studies, ex-vivo permeability, and in-vivo pharmacodynamics study. The optimized IBH-PNPs were found to be spherical (<200nm) and exhibited normal size distribution under transmission electron microscopy and atomic force microscopy respectively. The zeta potential and entrapment efficiency were found to be −43.75 mv and 60 ± 4.8% respectively. Developed IBH-PNPs analyzed for in-vitro drug release where they exhibited biphasic release. The ex-vivo drug permeation study showed 1.85 folds increment in intestinal permeability as compared to IBH tablets. The in-vivo anti-anginal efficacy studies were performed using vasopressin-induced angina model in Wistar rats. Developed formulation was found to have a therapeutic effect for three days.

Stable Angina Medical Therapy Management Guidelines: A Critical Review of Guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence.

Most patients with stable angina can be managed with lifestyle changes, especially smoking cessation and regular exercise, along with taking antianginal drugs. Randomised controlled trials show that antianginal drugs are equally effective and none of them reduced mortality or the risk of MI, yet guidelines prefer the use of beta-blockers and calcium channel blockers as a first-line treatment. The European Society of Cardiology guidelines for the management of stable coronary artery disease provide classes of recommendation with levels of evidence that are well defined. The National Institute for Health and Care Excellence (NICE) guidelines for the management of stable angina provide guidelines based on cost and effectiveness using the terms first-line and second-line therapy. Both guidelines recommend using low-dose aspirin and statins as disease-modifying agents. The aim of this article is to critically appraise the guidelines’ pharmacological recommendations for managing patients with stable angina.

Crystal structures and properties of two hydrated conglomerate forms of the heart-rate-lowering agent ivabradine hydrochloride.

Ivabradine hydrochloride (IVA-HCl) (systematic name: {[3,4-dimethoxybicyclo[4.2.0]octa-1(6),2,4-trien-7-yl]methyl}[3-(7,8-dimethoxy-2-oxo-2,3,4,5-tetrahydro-1H-3-benzazepin-3-yl)propyl]methylazanium), is a novel medication used for the symptomatic management of stable angina pectoris. In many recent patents, it has been claimed to exist in a very large number of polymorphic, hydrated and solvated phases, although no detailed analysis of the structural features of these forms has been published to date. Here, we have successfully crystallized the tetrahydrate form of IVA-HCl (form β), C27H37N2O5+·Cl-·4H2O, and elucidated its structure for the first time. Simultaneously, a new crystal form of IVA-HCl, i.e. the hemihydrate (form II), C27H37N2O5+·Cl-·0.5H2O, was discovered. Its crystal structure was also accurately determined and compared to that of the tetrahydrate form. While the tetrahydrate form of IVA-HCl crystallized in the orthorhombic space group P212121, the new form (hemihydrate) was solved in the monoclinic space group P21. Detailed conformational and packing comparisons between the two forms have allowed us to understand the role of water in the crystal assembly of this hydrochloride salt. The stabilities of the two forms were compared theoretically by calculating the binding energy of the water in the crystal lattice using differential scanning calorimetry (DSC). The stability experiments show that the tetrahydrate is stable under high-humidity conditions, while the hemihydrate is stable under high-temperature conditions.

SIGN guidelines: current management of stable angina

British Journal of Cardiac NursingVol. 13, No. 7 Policy UpdateSIGN guidelines: current management of stable anginaAlistair QuaileAlistair QuaileSearch for more papers by this authorAlistair QuailePublished Online:10 Jul 2018https://doi.org/10.12968/bjca.2018.13.7.322AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Montalescot G, Sechtem U, Achenbach S et al.. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003. https://doi.org/https://doi.org/10.1093/eurheartj/eht296 Crossref, Google ScholarNational Institute for Health and Care Excellence. Stable angina: management [CG126]. 2016. https://www.nice.org.uk/guidance/cg126 (accessed 26 June 2018) Scottish Intercollegiate Guidelines Network. Google ScholarManagement of stable angina [SIGN 96]. 2007. https://tinyurl.com/ybwvvwjn (accessed 26 June 2018) Google ScholarScottish Intercollegiate Guidelines Network. Management of stable angina [SIGN 151]. 2018. https://tinyurl.com/y93lu7fu (accessed 26 June 2018) Google Scholar FiguresReferencesRelatedDetails 2 July 2018Volume 13Issue 7ISSN (online): 2052-2207 Metrics History Published online 10 July 2018 Published in print 2 July 2018 Information© MA Healthcare LimitedPDF download

New NICE guidelines for the management of stable angina.

In November 2016, the National Institute for Health and Care Excellence (NICE) released an update of its 2010 Clinical Guideline CG951 on patients presenting with stable chest pain.2 This article covers the main changes in the updated CG95, and comments on how GPs can expect the management of patients referred to a cardiology/rapid-access chest pain clinic (RACPC) to change. Accurate assessment of patients presenting with chest pain is challenging. The combination of a detailed clinical history of the pain, with concomitant risk factors provides the most accurate clinical assessment.3,4 The 2010 guidance used pre-test probability scoring to guide patient investigation and management. The 2016 NICE guidelines do not advocate this and rely on a purely qualitative approach because all those with a clinical suspicion of angina will be investigated the same way. Presenting symptoms are divided into ‘typical’ and ‘atypical’. ‘Typical’ chest pain is classified as including all three of the following features: 1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; 2. Precipitated by physical exertion; and 3. Relieved by rest or sublingual nitrate within approximately 5 minutes. ‘Atypical’ pain is suggested by any two of the above, whereas ‘non-anginal’ pain is described as one or fewer. In the event of pain being classified as ‘non-anginal’, a diagnosis of stable angina can be excluded unless other features within the history or the risk factor profile (Box 1 …

Percutaneous Coronary Intervention in Stable Angina.

According to this study: The first blinded, placebo-controlled trial of percutaneous coronary intervention in patients with stable angina showed no significant difference in exercise time or angina symptom relief compared with patients who had a placebo intervention.However, the authors note that percutaneous coronary intervention shouldn't be ruled out for the management of stable angina.

FORMULATION AND CHARACTERIZATION OF SUSTAINED RELEASE MATRIX TABLETS OF IVABRADINE USING 32 FULL FACTORIAL DESIGN

Objective: Ivabradine (IB) is anti-Ischemic drug and used for the symptomatic management of stable angina pectoris. IB acts by reducing the heart rate in a mechanism different from beta blockers and calcium channel blockers, two commonly prescribed anti-anginal drugs. IB has a short biological half-life and the dose of 5/7.5 mg twice a day. In this present study, an attempt has been made to prepare sustained release tablet of IB to achieve the desired drug release.Methods: The sustained release polymers, hydroxypropyl methylcellulose K100M (HPMC K100M), guar gum (GG) and xanthan gum (XG) were taken for the preliminary trail from which guar gum and xanthan gum had shown better drug release. Initially, drug-excipients compatibility studies were carried out by using Fourier transformed infrared spectroscopy (FTIR) and Differential Scanning Calorimetry (DSC) which showed no interaction between drug and excipients. Tablets were prepared by wet granulation technique and evaluated for pre-compression and post-compression parameters.Results: 32 full factorial design was applied to achieve controlled drug release up to 24 h. The concentration of GG (X1) and XG (X2) were selected as independent variables and the % CDR at 2 h. (Y1) and 18 h. (Y2) were taken as dependent variables. In vitro drug release study revealed that as the amount of polymers increased, % CDR decreased.Conclusion: Contour as well as response surface plots were constructed to show the effect of X1 and X2 on % CDR and predicted at the concentration of independent variables X1 (10 mg) and X2 (10 mg) for a maximized response. The optimized batch (O1) was kept for stability study at 40±2 °C/75±5 %RH for a period of 6mo according to ICH guidelines and found to be stable.

ORBITA: What Goes Around, Comes Around… Or Does It?

Current guidelines recommend percutaneous coronary intervention (PCI) in patients with ongoing stable angina symptoms despite optimal medical therapy (OMT), although trials have shown no reduction in death or myocardial infarction. The recently published ORBITA trial compared OMT + PCI with OMT + 'placebo' PCI in patients with angina and single-vessel coronary artery disease (CAD), and found no significant difference in treadmill exercise time between the two groups after six weeks. The trial concluded that invasive procedures can be assessed with placebo control while numerous editorials interpreted the trial as showing that PCI has no role in the management of stable angina. However, the highly selected patient population, low ischaemic burden and level of symptoms and high proportion of non-flow-limiting stenoses on invasive physiological testing mean that, while ground-breaking in terms of its methodology, ORBITA does not add to the current evidence base supporting ischaemia-guided revascularisation if symptoms are not controlled on medical therapy alone.