Management Of Stable Angina Research Articles

Bridging the practice chasm

This editorial refers to ‘The clinical characteristics and investigations planned in patients with stable angina presenting to cardiologists in Europe: from the Euro Heart Survey of Stable Angina’† by C.A. Daly et al. , on page 996, and ‘The initial management of stable angina in Europe, from the Euro Heart Survey. A description of pharmacological management and revascularization strategies initiated within the first month of presentation to a cardiologist in the Euro Heart Survey of Stable Angina’‡ by C.A. Daly et al. , on page 1011 Since the description of angina by Herberden in 1768, the management of patients with angina has improved significantly. Over the past decades, several novel diagnostic and therapeutic techniques have provided better means of detection and treatment. Even with these favourable innovations, numerous studies have consistently demonstrated a wide discrepancy between knowledge and practice. Under-treatment of patients with acute coronary syndromes has been documented in the countries of North America,1,2 Europe,3 and around the world.4 Unlike the commercialization of other technological devices, the introduction of medical products requires a long and arduous process of pre-clinical and clinical studies. On the basis of these results, a panel of eminent specialists in the field, gathered by reputable medical organizations, develops guidelines to assist clinicians in the management of these conditions. Generally, this information is disseminated through international scientific meetings and key medical journals. Notwithstanding the extensive efforts in this exercise, Daly et al. … *Corresponding author. Tel: +65 6476 0880; fax: +65 6475 0880. E-mail address : makkh001{at}yahoo.com

The initial management of stable angina in Europe, from the Euro Heart Survey

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

Medical versus interventional management of stable angina.

Several randomized trials have been performed comparing medical management with surgery, medical management with angioplasty, and angioplasty with surgery for patients with stable angina. They were conducted in parallel with the progress of the revascularization techniques and as such, each of them reflects the prevailing practice of its time. Percutaneous revascularization and, to a lesser extent, coronary surgery have been, and it seems they will continue to be, rapidly evolving specialities. Medical management has also improved and future advances are likely to occur. One of the most remarkable advances in medical management is a new concept in metabolic approach in the treatment of angina pectoris. Despite the complexity of drawing conclusions from trials that compared approaches already outperformed in current practice, in this paper we review the relevant literature in an attempt to outline the comparative efficacy of the available treatment strategies.

Nicorandil: a review of its use in the management of stable angina pectoris, including high-risk patients.

Nicorandil (Adancor, Angicor, Dancor, Nikoril [Europe], Ikorel [Europe and Oceania], Sigmart [Japan, Korea and Taiwan]) is an adenosine triphosphate (ATP)-sensitive potassium (KATP) channel agonist with nitrate-like properties used in the management of stable angina pectoris. With well established monotherapeutic antianginal activity and a beneficial effect (when added to optimal antianginal therapy) on clinical outcomes in high-risk patients with stable angina, twice-daily oral nicorandil is a useful alternative or addition to other antianginal therapy.

Review: The management of stable angina in diabetes

Cardiovascular atherosclerosis is the commonest underlying cause of death in patients with diabetes mellitus. The development of atherosclerosis is often accelerated and the outcome is worse in diabetic than non-diabetic patients. This may relate to abnormalities of platelet function, coagulation, blood pressure and lipid metabolism that are characteristic of diabetes. Management of angina in diabetes should focus on reducing symptoms and prolonging life. In both of these areas there are issues specific to the diabetic patient. The role of percutaneous and surgical approaches to coronary disease in diabetic patients continues to evolve and optimal therapy remains unclear. Herein explores the clinical management of coronary artery disease in patients with diabetes. The pathophysiological basis of stable and unstable coronary syndromes is explained and the effect of diabetes on coronary disease and its subsequent management is discussed.

Management of Stable Angina and Unstable Angina/Non-ST-elevation Myocardial Infarction

Angina is a common symptom associated with considerable morbidity and mortality; with proper management, both can be reduced. N1 patients (with the lmssible exception of the verv elderly with mild symptoms) should be referred to a cardiologist forassessment.The comerstones of management include establishingthe diagnosis, treating the s)Tnptoms, determining the risk of future adverse events and implementing measures to improve theprognosis. Well-vadidated tests, effective treatments and excellentscientific data are available to assist the physician. Nevertheless,the optimal ilkanagement of individual patients renkains a matter ofclinical judgement.

Improved Coronary Risk Assessment With Electron Beam Computed Tomography in an Asymptomatic Female With Familial Hypercholesterolemia

Improved Coronary Risk Assessment With Electron Beam Computed Tomography in an Asymptomatic Female With Familial Hypercholesterolemia

Development of review criteria for assessing the quality of management of stable angina, adult asthma, and non-insulin dependent diabetes mellitus in general practice.

OBJECTIVE: To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus. SUBJECTS AND METHODS: Modified panel...

Effective management of stable angina.

Effective management of stable angina.

How European cardiologists perceive the role of calcium antagonists in the treatment of stable angina.

Some 100 European cardiologists discussed calcium antagonists' role in the management of stable angina. Sixty-two percent of those involved used calcium antagonists rather than beta-blockers as first line therapy; 46% were prepared to use calcium antagonists in patients who had had a myocardial infarction more than 6 months previously. Only one tenth would use calcium antagonists in angina patients with left ventricular dysfunction. There was a broad preference for the use of heart rate-moderating calcium antagonists in most forms of stable angina. The discussions also underlined the diagnostic importance of angiography, exercise testing and lipid profile analysis.

Guidelines on managing stable angina omit important point

EDITOR,—The North of England Stable Angina Guideline Development Group has provided concise and authoritative recommendations for the management of stable angina in primary care.1 They do not, however, say anything about …

North of England evidence based guidelines development project: summary version of evidence based guideline for the primary care management of stable angina

The aim of this guideline is to provide recommendations to aid primary health care professionals in their management of patients with chronic stable angina due to coronary artery disease (not aortic stenosis or hypertrophic obstructive cardiomyopathy). It does not deal with unstable angina or myocardial infarction. It is a summary version of the full guideline,1 to which reference should be made for clarification or further information. The development group assumes that health care professionals will use general medical knowledge and clinical judgment in applying the general principles and specific recommendations in this document to the management of individual patients. Recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner in the light of available resources and circumstances presented by individual patients. Throughout this guideline categories of evidence (cited as I, II, and III) and the strength of recommendations (A, B, or C) are as described in the paper in the previous issue (23 March, p 760). Aspects covered by this guideline are investigation, risk factor identification and management, drug treatment, and referral. All recommendations are for primary health care professionals and apply to adult patients attending general practice with angina. Comment—Assessment will be based on a clinical history and relevant examination. This guideline requires that the following should be known: precipitants of anginal attacks; smoking history; occupation; amount of exercise taken; drug history; weight; blood pressure. Comment—The group thought that a chronological age limit for investigation or referral was not appropriate. Functional status was thought to be more appropriate. ### Precipitating factors RECOMMENDATION ### Investigation of angina RECOMMENDATION Patients being investigated for angina should have the following investigations:

Medical Management of Stable Angina and Unstable Angina in the Elderly With Coronary Artery Disease

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

Bisoprolol: Is This Just Another Beta-Blocker for Hypertension or Angina?

To review the pharmacology, pharmacokinetics, and clinical experience with bisoprolol and make recommendations regarding its potential clinical usefulness, as well as considerations for formulary inclusion. Reference citations were sought from Index Medicus and Science Citation Index. Data were collected from abstracts and articles describing experimental studies or blind clinical trials. Studies designed in a randomized, blind, and placebo-controlled manner were emphasized. Studies also were included if bisoprolol was evaluated comparatively with other agents in a randomized, blind fashion. Data from human studies published in English were evaluated. Studies were assessed by sample size and the clarity of descriptions of methods and results. Bisoprolol reduces systolic and diastolic blood pressures in patients with hypertension for a 24-hour dosing interval and is associated with beneficial hemodynamic effects in patients with myocardial ischemia. It is devoid of intrinsic sympathomimetic activity and membrane-stabilizing effects at therapeutic dosages. In patients with hypertension, bisoprolol diminishes plasma renin activity, platelet aggregation, effective renal plasma flow, and creatinine clearance. Bisoprolol has minimal effects on glucose tolerance and plasma lipid profiles. Monotherapy with bisoprolol is as effective as with atenolol, nitrendipine, or nifedipine. Low-dose combination therapy with hydrochlorothiazide is at least as effective as either bisoprolol or hydrochlorothiazide alone. Preliminary experience in the management of angina pectoris suggests that bisoprolol is at least as efficacious as atenolol or verapamil. Thus far, reported adverse effects are similar to those of other beta-blockers. No clinically important drug interactions have been reported at this time.

Amlodipine in chronic stable angina: Results of a multicenter double-blind crossover trial

The efficacy and safety of amiodipine, 10 mg, a new long-acting calcium antagonist, was compared with placebo in 103 patients with stable angina pectoris in a multicenter double-blind crossover study. The trial consisted of an initial 2-week single-blind placebo period followed by a first period of 4 weeks at double-blind therapy, which was followed by a 1 week washout perioid and then a second 4-week double-blind period after treatments were crossed over. Twenty-four—hour Holter electrocardiographic monitoring was carried out in 12 patients at three centers. In the first double-blind period amiodipine prodcued a significantly greater increase in symptom-limited exercise duration (amiodipine 478.5 to 520.6 vs placebo 484.6 to 485.2 seconds; change +8.8% vs +0.1%, respectively; p = 0.0004) and total work (amiodipine 2426 to 2984 vs placebo 2505 to 2548 kilopondmeters; change +24% vs +1.7%, respectively; p = 0.0006) and a decrease in angina attack frequency (from 3 to 1 per week; p = 0.016) and nitroglycerin consumption (from 2 to 0.5 tablets/wk; p = 0.01) compared with placebo. Holter monitoring revealed significant reductions in numbers (amiodipine 4.65 to 2.22 vs placebo 1.84 to 1.54; change +52% vs +84%, respectively; p = 0.06), absolute total area (amiodipine 87.66 to 11.43 vs placebo 5.76 to 35.24; change +87% vs +513%, respectively; p = 0.02), and duration (amiodipine 12.29 to 2.95 vs 1.66 to 7.74 seconds; change +76% vs +367%, respectively; p = 0.008) of ST-segment depressions after treatment with amiodipine compared with placebo. After the treatments were crossed over changes continued to favor amiodipine. However, there were no significant changes by Holter monitoring in any of the ST-segment parameters during the period after the crossover. The smaller changes with amiodipine during the period after the crossover may be the result of the long half-life of amiodipine or an exercise training effect. The most frequently reported side effects with amiodipine were headache (11%) and edema (8%). We conclude that amiodipine therapy is well tolerated and that it demonstrates antiischemic and antianginal efficacy in the management of stable angina.

The Management of Stable Angina

Angina pectoris is a clinical diagnosis that must be accurate and cannot be L'1. made lightly. The diagnosis usually reflects the presence of significant coronary artery disease, whose location, extent, and severity, along with the presence or absence of left ventricular dysfunction, determine the patient's prognosis. If there is any doubt about the diagnosis, it must be clarified. At the outset, it is particularly important to identify those at greatest risk for myocardial infarction and death-those whose lives might well be shortened unless an aggressive approach is taken. Management, however, cannot focus entirely on relieving symptoms and increasing longevity. A diagnosis of angina (or any other form of heart disease) threatens not only the patient's well-being but also family and friends as well as the patient's working life-a matter of particular importance in these recessionary times. Angina is as much a psychological problem as a hemodynamic and prognostic one. In the case to be described, the clinical diagnosis was clear, but the patient had only mild symptoms. His angina was stable: It occurred predictably during exercise and was rapidly relieved by rest. It did not occur at rest, nor was it of recent

Parasympathetic Blockade with Benzhexol Hydrochloride (Trihexyphenidyl Hydrochloride) in the Management of Stable Angina Pectoris

Parasympathetic Blockade with Benzhexol Hydrochloride (Trihexyphenidyl Hydrochloride) in the Management of Stable Angina Pectoris

Contemporary medical management of stable angina pectoris

Contemporary medical management of stable angina pectoris

Drug management of stable angina pectoris

Nitroglycerin and long-acting nitrates are the pharmacologic mainstays of antianginal therapy, both for acute attacks and for prophylaxis. Propranolol is often effective for prophylaxis in patients incompletely helped by nitrates. A holistic approach is stressed. Appropriate drug use will effect marked improvement in most pateints.

Management of stable angina.

THE mechanism of the production of angina pectoris remains unclear.1 However, angina pectoris due to coronary-artery disease is generally considered to be chest pain due to myocardial ischemia that occurs because the myocardial oxygen demand exceeds the myocardial oxygen supply.The most sensible approach to the problem of coronary heart disease is the reduction, when possible, of the many risk factors that predispose to the development of the disease. However, once angina pectoris develops, the physician is faced with the problem of providing pain relief to the patient. In addition to relief of pain, an ideal antianginal drug would also . . .