Persistent Angina Research Articles

Stress Testing After Complete and Successful Coronary Revascularization

BackgroundNoninvasive stress tests play a determinant role in the initial management of patients with chronic angina. Nonetheless, their use in the same patient population is considered inappropriate within 2 years after percutaneous coronary intervention (PCI). Indeed, early abnormal results correlate less well with angiographic control and are attributed to a number of confounding factors. We prospectively assessed prevalence and impact on the quality of life of abnormal stress test results in a highly selected patient population. MethodsPatients with no cardiac comorbidities who underwent successful and complete PCI with stenting for typical angina and had an abnormal exercise stress test (EST) under guideline-directed medical treatment were administered the Seattle Angina Questionnaire (SAQ). Clinical evaluation, EST, and the SAQ were repeated at 1, 6, and 12 months after the index PCI. ResultsOne hundred ninety-eight patients qualified and were included in the study (mean age, 64 years; 79% men). Although the majority had normal EST results or an increased threshold to angina, at 1 month after the index PCI, 29% of patients still had an abnormal result. At 6 and 12 months, 31% and 29% of patients had abnormal results, respectively. Quality-of-life assessment by the SAQ showed consistent results, with persistent angina in one third of patients. Control angiography documented a critical lesion, attributable to in-stent coronary restenosis, in only 8% of patients. ConclusionsWhen stress testing is systematically performed after PCI, the prevalence of abnormal results is high and is associated with impaired quality of life. Prognostic significance along with the underlying pathophysiological mechanisms of such findings should be investigated.

Coronary artery vasospasm and cardiogenic shock as the initial presentation for eosinophilic granulomatosis with polyangiitis

A 68-year-old woman presented to our hospital with unstable angina and was admitted for further evaluation. While hospitalized, she developed persistent angina with hypotension along with ST-segment elevation in leads V1–V2 along with lead aVR elevation on 12-lead electrocardiogram. Coronary angiography revealed diffuse multi-vessel coronary vasospasm most notably in the left anterior descending artery (LAD). Due to incomplete resolution of vasospasm with intracoronary verapamil and nitroglycerin, along with hemodynamic compromise requiring an intra-aortic balloon pump, percutaneous coronary intervention (PCI) of the LAD was performed. Clinical workup revealed hypereosinophlia and elevated IgE; diagnosis of eosinophilic granulomatosis with polyangiitis was confirmed with evidence of radiographic migratory pulmonary infiltrates and airway obstruction on spirometry. The patient had recurrent angina after PCI but her symptoms resolved fully after a course of corticosteroids. We attribute her refractory vasospastic angina to previously undiagnosed small/medium-vessel vasculitis.<Learning objective: We present a case of refractory coronary artery vasospasm in the setting of eosinophilic granulomatosis with polyangiitis (EGPA). Typically, calcium channel blockers and nitrates are used to treat hyperreactive narrowing of the coronary vasculature but we propose this case was refractory to standard treatment due to the underlying pathology of EGPA. Alternative causes of coronary vasospasm when standard therapies fail should be considered.>

Coronary Microvascular Dysfunction, Microvascular Angina, and Management.

Recent analyses have found that coronary microvascular dysfunction (CMD) portends a poor prognosis in patients with and without obstructive epicardial coronary artery disease (CAD). Chest pain in the absence of epicardial CAD is a common entity. Angina caused by CMD, microvascular angina (MVA), is often indistinguishable from that caused by obstructive epicardial CAD. The recent emergence of noninvasive techniques that can identify CMD, such as stress positron-emission tomography (PET) and cardiovascular magnetic resonance (CMR) myocardial perfusion imaging, allow improved identification of MVA. Using these tools, higher risk patients with MVA can be differentiated from those at lower risk in the heterogeneous population historically labeled as cardiac syndrome X. Likewise, MVA can be diagnosed in those with obstructive epicardial CAD who have persistent angina despite successful revascularization. There is little evidence to support current treatment strategies for MVA and current literature has not clearly defined CMD or whether therapy improves prognosis.

‘Action potential-like’ ST elevation following pseudo-Wellens' electrocardiogram

Coronary artery vasospasm is an important cause of chest pain syndromes that can lead to myocardial infarction, ventricular arrhythmias, and sudden death. In 1959, Prinzmetal et al described a syndrome of nonexertional chest pain with ST-segment elevation on electrocardiography. Persistent angina is challenging, and repeated coronary angioplasty may be required in this syndrome. Calcium antagonists are extremely effective in treating and preventing coronary spasm, and may provide long-lasting relief for the patient. Whereas the Wellens' syndrome is characterized by symmetrically inverted T-waves with preserved R waves in the precordial leads suggestive of impending myocardial infarction due to a critical proximal left anterior descending stenosis, the pseudo-Wellens' syndrome caused by coronary artery spasm has also rarely been reported in literature. We present a pseudo-Wellens syndrome as a cause of vasospastic angina, and a diffuse ST segment elavation on electrocardiogram resembling the Greek letter lambda, called also 'action potential-like' ECG in a patient with vasospastic-type Printzmetal angina.

PP-024 Successful Trapping of a Warm-like Thrombus in an Ectatic Right Coronary Artery Causing Acute Myocardial Infarction

A 53-year-old male non-smoker with hypertension and hypercholesterolemia (LDL:215MG/DL) presented 2 hours after sudden onset of severe chest pain with persistent angina and ST elevations in the inferior leads. He received electroshocks because of ventricular fibrilation in the emergency department. Emergent coronary angiography showed right coronary artery (RCA) occlusion distal to a fusiform aneurysm of the proximal RCA and an occlusion of the vessel downstream due to a huge organized thrombus. There were also aneurysmatic and ectatic segments in the mid portion of left anterior descending and distal left circumflex arteries. An aspiration catheter was advanced to the RCA to aspirate the thrombus over an intermediate guidewire. A huge warm-like (>3cm) red thrombus was retrived from the guiding catheter by applying negative pressure. After the successful thrombectomy, TIMI 3 coronary flow was restored and ST elevation and chest pain of the patient resolved. Glycoprotein IIb/IIIa antagonist was administered during and 48 hours after the procedure along with unfractioned heparin, clopidogrel and ASA. The postoperative course was uneventful and the left ventricular ejection fraction was within the normal range without any wall motion abnormality.

Cardiac rehabilitation for cardiac syndrome X and microvascular angina: A case report

Introduction: Therapeutic strategies for cardiac syndrome X, characterized by the three features of angina, evidence of myocardial ischemia and no obstructive coronary artery disease, are not well known. Recent data indicate that angina secondary to microvascular coronary dysfunction is a common pathogenesis of cardiac syndrome X. While cardiac rehabilitation is well-known to be effective for angina due to obstructive coronary artery disease, less is known in cardiac syndrome X and microvascular angina patients. Case Report: A 34-year-old female with history of pre-eclampsia during three pregnancies, recurrent non-ST-segment-elevation myocardial infarctions, no obstructive coronary artery disease, microvascular coronary dysfunction documented by coronary reactivity testing, ischemic cardiomyopathy, overweight, factor V Leiden mutation, and persistent microvascular angina was referred to cardiac rehabilitation five weeks after a non-ST-segment-elevation myocardial infarction. The patient was taking a beta blocker, ACE, statin and low dose aspirin. She underwent four sessions of supervised cardiac rehabilitation program which progressed to a duration of 45 minutes at a level of 3.3 metabolic equivalents of aerobic exercise. A normal cardiovascular response without arrhythmias was observed. A home program was suggested with moderate intensity of aerobic exercise, 30– 45 minutes per day, most days of the week. She experienced decreased angina, improved quality of life and increased functional capacity at the fourth-year of follow-up. Conclusion: Cardiac rehabilitation was beneficial in the patient angina due to microvascular coronary dysfunction. Increased exercise intensity and duration, increased functional capacity, decreased anginal symptoms and improved quality of life were found.

EFFECT OF NICORANDIL IN PATIENTS WITH REFRACTORY ANGINA AND ADVANCED CORONARY ARTERY DISEASE

Refractory angina (RFA) is a chronic morbid condition hampering the quality of life of thousands of Canadians and effective therapies are desperately needed. Nicorandil is a nicotinamide vasodilator with cardioprotective effects that has been shown to improve cardiac outcomes in patients with stable coronary artery disease (CAD). Nicorandil has never been studied in patients with refractory angina. We investigated the safety and efficacy of nicorandil in patients with advanced coronary artery disease unsuitable for revascularization and persistent angina (CCS Class II to IV) despite maximal tolerable doses of two anti-angina agents, and compared it with similar control patients not exposed to nicorandil. Consecutive patients were selected from our RFA clinic from August 2009 to August 2013 and followed-up for at least 6 months. Nicorandil was available via the Health Canada’s special access program, and a pharmacist dedicated to the program monitored observance to nicorandil and the occurrence of drug-related adverse effects. We assessed the association between nicorandil and cardiovascular outcomes (1st endpoint) and CCS angina class (2nd endpoint) in patients with RFA. Forty patients treated with maximum orally tolerated dose of Nicorandil (up to 30 mg three times daily) were compared to 38 control patients (total n = 78). Baseline characteristics and cardiovascular status were similar in both groups as shown in Table 1. Over a median follow-up of 15 months, fewer patients treated with nicorandil experienced the combined occurrence of death or heart transplant + acute coronary syndrome + coronary revascularization + hospitalization rates at 1-year for angina compared to control patients (37.5% vs. 71.1%, p < 0.05). Nicorandil was associated with a significant improvement in the functional status, as shown in the figure.View Large Image Figure ViewerDownload (PPT) In patients with advanced coronary artery disease and RFA, Nicorandil is associated with both a reduction on cardiovascular events and improvement in functional class.

Functional assessment of multivessel coronary artery disease: ischemia-guided percutaneous coronary intervention.

Invasive evaluation and treatment of coronary artery disease (CAD) has traditionally been based upon coronary angiography to determine the need for and the success of revascularization. However, coronary angiography augmented with fractional flow reserve (FFR) creates a paradigm shift, providing a more complete functional assessment of coronary lesions. Measuring FFR to identify ischemic lesions and guide revascularization results in fewer adverse outcomes, including persistent angina, myocardial infarction, and mortality. An ischemic lesion identified by FFR is more likely to lead to adverse events when compared with an angiographically similar lesion with nonischemic FFR when both are treated medically. Although the mechanism explaining this is unclear, it is likely multifactorial, including the impact of mechanical forces, upregulation of inflammatory mediators, and the amount of distal myocardial tissue at risk. Using both anatomic and ischemia-guided assessments (such as the Functional SYNTAX Score) aids in the therapeutic decision-making process in patients with multivessel CAD. This review focuses on the evidence for FFR-guided management of multivessel CAD.

OSA and Depression Are Common and Independently Associated With Refractory Angina in Patients With Coronary Artery Disease

Refractory angina is a severe form of coronary artery disease (CAD) characterized by persistent angina despite optimal medical therapy. OSA and depression are common in patients with stable CAD and may contribute to a poor prognosis. We hypothesized that OSA and depression are more common and more severe in patients with refractory angina than in patients with stable CAD. We used standardized questionnaires and full polysomnography to compare consecutive patients with well-established refractory angina vs consecutive patients with stable CAD evaluated for coronary artery bypass graft surgery. Patients with refractory angina (n = 70) compared with patients with stable CAD (n = 70) were similar in sex distribution (male, 61.5% vs 75.5%; P = .07) and BMI (29.5 ± 4 kg/m2 vs 28.5 ± 4 kg/m2, P = .06), and were older (61 ± 10 y vs 57 ± 7 y, P = .013), respectively. Patients with refractory angina had significantly more symptoms of daytime sleepiness (Epworth Sleepiness Scale score, 12 ± 6 vs 8 ± 5; P < .001), had higher depression symptom scores (Beck Depression Inventory score, 19 ± 8 vs 10 ± 8; P < .001) despite greater use of antidepressants, had a higher apnea-hypopnea index (AHI) (AHI, 37 ± 30 events/h vs 23 ± 20 events/h; P = .001), higher proportion of oxygen saturation < 90% during sleep (8% ± 13 vs 4% ± 9, P = .04), and a higher proportion of severe OSA (AHI ≥ 30 events/h, 48% vs 27%; P = .009) than patients with stable CAD. OSA (P = .017), depression (P < .001), higher Epworth Sleepiness Scale score (P = .007), and lower sleep efficiency (P = .016) were independently associated with refractory angina in multivariate analysis. OSA and depression are independently associated with refractory angina and may contribute to poor cardiovascular outcome.

Persistent angina pectoris in ischaemic cardiomyopathy: increased rehospitalization and major adverse cardiac events.

The impact of refractory angina pectoris (AP) in patients with ischaemic cardiomyopathy (ICM) is unknown. We investigated the characteristics and outcomes of ICM patients with persistent AP following cardiac catheterization. Patients who underwent coronary angiography at Duke from 2000 to 2009 with an EF <40% and ICM with persistent AP were compared with similar patients without persistent AP. Persistent AP was defined by patient report of ischaemic symptoms within 1 year of index catheterization. Time-to-event was examined using Kaplan-Meier or cumulative incidence and Cox proportional hazards modelling methods for death/myocardial infarction (MI)/revascularization [i.e. major adverse cardiac events (MACE)], death/MI, death, and cardiovascular death/hospitalization. Of 965 ICM patients, 298 (31%) had persistent AP. These patients were younger and had more previous revascularization than patients without persistent AP. Both groups had high use of aspirin, beta-blockers, ACE inhibitors, and statins, but modest nitrate use. Over a median follow-up of >5 years, patients with persistent AP had increased rates of MACE, and cardiovascular death/hospitalization compared with patients without persistent AP [5-year cumulative event rates of 53% vs. 46% (P = 0.013) and 73% vs. 60% (P < 0.0001), respectively], but similar rates of death (P = 0.59) and death/MI (P = 0.50). After multivariable adjustment, persistent AP remained associated with increased MACE [hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.08-1.57], and cardiovascular death/hospitalization (HR 1.36; 95% CI 1.14-1.62). Persistent AP is common despite medical therapy in patients with ICM and is independently associated with increased long-term MACE and rehospitalization. Future prospective studies of persistent AP in ICM patients are warranted.

Dual antiplatelet therapy in patients with stable coronary artery disease in modern practice: Prevalence, correlates, and impact on prognosis (from the Suivi d’une cohorte de patients COROnariens stables en region NORd-Pas-de-Calais study)

The prevalence and correlates of dual-antiplatelet therapy (DAPT) use in stable coronary artery disease (CAD) are unknown. In addition, whether prolonged DAPT may impact prognosis in stable CAD has not been studied in real-life conditions. We studied 3,691 patients included in a prospective registry on stable CAD. The patients were divided in 2 groups according to their antiplatelet therapy regimen at inclusion: patients treated with DAPT were compared with those treated with single-antiplatelet therapy (SAPT). The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke. Altogether, 868 (24%) patients received DAPT. Factors positively associated with DAPT use were persistent angina at inclusion, body mass index, myocardial infarction since 1 to 3 years, myocardial revascularization since 1 to 3 years, multivessel CAD, prior drug-eluting stent implantation, and prior aortic or peripheral intervention. Factors negatively associated with DAPT use were age, prior coronary bypass, and left ventricular ejection fraction. The rate of the primary outcome at 2 years was similar whether patients were treated with SAPT (4.6%) or DAPT (5.5%) (P = .301). Similar rates were also observed after propensity score matching: 5.7% when treated with SAPT versus 5.5% when treated with DAPT (P = .886). The rate of bleeding was similar between groups. Our study shows that a significant proportion of stable CAD patients are treated with DAPT in modern practice. Several correlates of DAPT were identified. Although no increase in bleeding was observed, our results do not support the prescription of prolonged DAPT.

Influence of Stent Length on Peri-Procedural Myocardial Injury after Percutaneous Coronary Intervention

Background: About one-third of all elective PCI procedures are associated with significant myocardial injury termed peri-procedural myocardial injury (PMI), which has been associated with increased subsequent mortality. The stent length is one of the factors that can predict procedure related Troponon I release. Methods: This interventional study was carried out to evaluate the influence of stent length on peri– procedural myocardial injury by measuring post procedural release of Troponin I after percutaneous coronary intervention. Patients with e”70% stenosed single vessel disease undergoing percutaneous coronary intervention with single stent were considered. Exclusion criteria were pre-procedural elevation of cardiac Troponin I above the 99th percentile of upper reference, severely ill patients. Total 90 consecutive patients were included. Among them 45 patients had d” 20mm long stent (group A) and rest 45 patients had &gt; 20mm long stent (group B). Blood samples for Troponin I were collected before procedure and 12 hours after procedure. Results: Baseline characteristics including age, sex, risk factor for ischaemic heart disease and clinical diagnoses were almost similar between the two groups. During procedure no complications concurred 93.3% patients in group A and 68.9% patients in group B (p&lt;0.05). Post procedural Troponin I level in group A was 0.47 ± 0.54 and in group B was 0.99 ± 1.09 (p&lt;0.05). The stent length and post procedural Troponin I level had moderate correlation (r=0.41) (p&lt;0.05). In hospital complications in two groups include persistent angina (6.7% vs. 11.1%), new ischaemic episode (0.0% vs. 4.4%) (p&gt;0.05). There were no myocardial infarction, acute left ventricular failure, emergency CABG, arrhythmia and death in both groups. Durations of hospital stay were significantly higher in group B then group (4.53 ± 0.63 vs. 4.07 ± 0.65, p&lt;0.05). Conclusion: The incidence of procedural myocardial injury and procedural complications are more in longer stent group. So limiting the stent length by spot-stenting the lesions rather than covering the entire vessel between lesions may reduce peri-procedural release of cTnI and improve post procedural prognosis. DOI: http://dx.doi.org/10.3329/cardio.v6i2.18358 Cardiovasc. j. 2014; 6(2): 143-148

Mortality Implications of Angina and Blood Pressure in Hypertensive Patients With Coronary Artery Disease: New Data From Extended Follow‐up of the International Verapamil/Trandolapril Study (INVEST)

Angina and hypertension are common in patients with coronary artery disease (CAD); however, the effect on mortality is unclear. We conducted this prespecified analysis of the International Verapamil/Trandolapril Study (INVEST) to assess relationships between angina, blood pressure (BP), and mortality among elderly, hypertensive CAD patients. Angina and elevated BP will be associated with higher mortality. Extended follow-up was performed using the National Death Index for INVEST patients in the United States (n = 16 951). Based on angina history at enrollment and during follow-up visits, patients were divided into groups: persistent angina (n = 7184), new-onset angina (n = 899), resolved angina (n = 4070), and never angina (n = 4798). Blood pressure was evaluated at baseline, during drug titration, and during follow-up on-treatment. On-treatment systolic BP was classified as tightly controlled (<130 mm Hg), controlled (130-139 mm Hg), or uncontrolled (≥140 mm Hg). A Cox proportional hazards model was created adjusting for age, heart failure, diabetes, renal impairment, myocardial infarction, stroke, and smoking. The angina groups and BP control groups were compared using the never-angina group as the reference. Only in the persistent-angina group was a significant association with mortality observed, with an apparent protective effect (hazard ratio: 0.82, 95% confidence interval: 0.75-0.89, P < 0.0001). Uncontrolled BP was associated with increased mortality risk (hazard ratio: 1.29, 95% confidence interval: 1.20-1.40, P < 0.0001), as were several other known cardiovascular risk factors. In hypertensive CAD patients, persistent angina was associated with lower mortality. The observed effect was small compared with other cardiovascular risk factors, such as BP, which were associated with increased mortality.

Persistent angina: highly prevalent and associated with long-term anxiety, depression, low physical functioning, and quality of life in stable angina pectoris

To evaluate persistent angina in stable angina pectoris with no obstructive coronary artery disease (CAD) compared to obstructive CAD and its relation to long-term anxiety, depression, quality of life (QOL), and physical functioning. We invited 357 patients (men = 191; women = 166; response rate 83 %) with no prior cardiovascular disease who had a first-time coronary angiography (CAG) in 2008-2009 due to suspected stable angina to participate in a questionnaire survey in 2011 with the Seattle Angina Questionnaire and the Hospital Anxiety and Depression Scale as key elements. Long-term persistent angina (i.e., symptoms at least once a month) was present in 64 % of patients with diffuse non-obstructive CAD (1-49 % stenosis), 49 % of patients with normal coronary arteries (0 % stenosis), and 41 % of patients with obstructive CAD (≥ 50 % stenosis) (P = 0.01). Depression and anxiety were more common in patients with persistent angina: 24 versus 7 % (P < 0.001) reported HADS-Depression-scores >7 and 42 versus 21 % (P < 0.001) reported HADS-Anxiety-scores >7. In multivariate regression models, persistent angina was associated with depression (OR 4.3, 95 % confidence interval (CI) 1.9-9.6, P < 0.001), anxiety (OR 2.9, 95 % CI 1.6-5.1, P < 0.001), the severity of persistent angina with impaired physical functioning (P < 0.001), and QOL (P < 0.001); whereas outcomes were not related to age, gender, or degree of CAD. The study indicates higher prevalence of persistent angina in patients with diffuse non-obstructive CAD or normal coronary arteries than in patients with obstructive CAD. Persistent angina symptoms were associated with long-term anxiety, depression, impaired physical functioning, and QOL irrespective of the degree of CAD. Contrary to common perception, excluding obstructive CAD in stable angina does not ensure a favorable disease course, and further risk stratification and treatment strategies are warranted.

Neu aufgetretener linksventrikulärer Thrombus im Verlauf einer Tako-Tsubo-Kardiomyopathie

A 70-year-old woman complained of persistent angina pectoris and exertional dyspnoea after a fierce row with a dog owner. Five days after the conflict she visited our clinic. The ECG showed T-wave inversions across the inferior and anterior leads as well as a prolonged QTc interval (490 ms). NTproBNP was elevated (6733 ng/l) while troponin T was normal. Echocardiography and ventriculography during cardiac catheterisation demonstrated an impaired left ventricular function (EF 55 %) with apical akinesia. Coronary artery disease was ruled out by coronary angiography. Based on these findings stress-related cardiomyopathy (Tako-tsubo syndrome) was diagnosed. Guideline-based therapy of heart failure was performed. At control examination 13 days after the initial event left ventricular function had improved but now a new left ventricular apical thrombus was detected. Therefore, oral anticoagulation therapy was started. In cases of tako-tsubo cardiomyopathy with apical akinesia it should be noted that a left ventricular thrombus can develope within few days.

Some thoughts on the continuing dilemma of angina pectoris

electrocardiographic abnormalities. 5 Many reports followed documenting ischaemia by different methods in such patients but, in contrast to ischaemia associated with obstructive CAD, left ventricular wall motion appeared to be preserved. This finding led to speculation about long-term outcomes of such patients. Indeed multiple early reports suggested that outcomes were similar to those of selected subjects without angina and obstructive CAD. Unfortunately, this conclusion was widely embraced and led to dismissal of such patients from subspecialty care and also from general medical care. During our attempts to identify reasons for higher ischaemic heart disease (IHD) event rates among women vs. men, it became clear that there was a strong bias against evaluation of women with chest pain and other findings suggesting IHD. The public message about this gender inequity then prompted referral of more women with these findings to coronary angiography. We began to see increasing numbers of such women who were not only disabled by persistent angina, but had serious adverse outcomes. These concerns led to the WISE study in 1996, and about two-thirds of the initial consecutive cohort of women with chest pain and other findings suggesting IHD were found to have no obstructive CAD: their adverse outcomes confirmed that this was not a benign syndrome, as initially believed. 2 Also important was the application of coronary artery reactivity testing for endothelial and microvascular function (Figure 1). Among women with normal coronary arteries and non-obstructive CAD, WISE study data showed that most had endothelial and/or microvascular dysfunction. The latter was defined by low coronary flow reserve and independently predicted adverse cardiovascular events (e.g. first occurrence of death, myocardial infarction, stroke, or hospitalization for heart failure) after 5.4 years followup. 3 These serious events are consistent with the cardiovascular disease continuum expected for a disorder involving the microvasculature. Furthermore, they consume a large amount of healthcare resources. Cardiac magnetic resonance imaging provided superior resolution to evaluate perfusion, and these patients were found to have a relative failure of subendocardial perfusion to increase with adenosine, which could explain the absence of major changes in left ventricular wall motion. 6

Persistent Angina Pectoris, Cardiac Mortality and Myocardial Infarction During a 12 Year Follow-Up in 273 Variant Angina Patients Without Significant Fixed Coronary Stenosis

The incidence of cardiac events in patients with variant angina pectoris without significant coronary stenosis and ST-segment elevation was analyzed during a 12-year follow-up period in 273 consecutive patients (82% men) admitted from 1986 through 2010. Among the 252 patients who underwent electrocardiography during pain, 205 had ST-segment elevation (82%) and 45 had ST-segment depression (18%). During index hospitalization, angina occurred in 179 patients (66%), ventricular tachycardia or fibrillation in 28 (10%), and complete atrioventricular block in 3 (1%), but there were no deaths or myocardial infarctions (MIs). At 140 months, angina was still present in 129 patients (47%), but frequent angina (>10 episodes/year) occurred in only 6%. Total mortality, cardiac mortality, and MI rates were 24%, 7.0%, and 6%, respectively. Cardiac death or MI occurred in 28 patients (10%), associated with tobacco smoking (p = 0.004), antecedent "first-wind" angina (p = 0.020), and angina during hospitalization (p = 0.044) and with continued smoking (p = 0.056) and recurrent angina during follow-up (p <0.001). Multivariate analysis identified age (p = 0.001), antecedent infarction (p = 0.005), first-wind angina (p = 0.009), and smoking at index hospitalization (p = 0.027) as predictors of total mortality and treatment with calcium antagonists (p = 0.047) and smoking during follow-up (p = 0.110) for cardiac mortality and MI. In conclusion, during 12-year follow-up, patients with variant angina pectoris, mostly with ST-segment elevation during pain, had a reduced incidence of cardiac mortality and MI, associated with first-wind angina, persistent angina, and continued smoking.

Effects of Aging on the Collateral Circulation, and Therapeutic Implications

> That time of year thou mayst in me behold, When yellow leaves, or none, or few, do hang Upon those boughs which shake against the cold, Bare, ruined choirs, where late the sweet birds sang. > > —Shakespeare, Sonnet 73 The most important mechanism by which the body compensates for the reduced tissue flow caused by an obstructed artery is through flow supplied by the collateral circulation. Thus, when arterial obstruction occurs, perfusion to the ischemic tissue is provided by collateral vessels—defined as vessels, usually from an adjacent arterial tree, that interconnect the proximal part of an arterial circuit to that part of the artery lying distal to an obstruction. Important as the collateral circulation is, it is often incapable of restoring flow to normal levels at rest, and is usually incapable of delivering the augmented flow required by exercise or increased metabolic demands, as evident by the frequency of patients experiencing either angina or claudication in cohorts with coronary or peripheral vascular disease. The limited capacity to restore full flow at high metabolic demands poses quality-of-life issues to individuals who have chronic arterial obstruction: in the United States alone 300 000 to 900 000 patients have persistent angina despite medical management.1 Additionally, both animal and human studies demonstrate that the clinical outcome of acute arterial obstruction is worse in animals/patients with poor collaterals versus those with a robust collateral circulation.2–5 These considerations led to major efforts to develop strategies designed to enhance collateral function, including administration of proteins and genes expressing such proteins, and stem or progenitor cells known to secrete factors that improve collateral function. However, despite proof-of-concept studies in animals, strategies tested to date in patients are inconclusive; some studies have failed to demonstrate clinical improvement, and others reporting positive signals are based on too few patients for …

Initial Coronary Stent Implantation With Medical Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease

Prior meta-analyses have yielded conflicting results regarding the outcomes of treatment of stable coronary artery disease (CAD) with initial percutaneous coronary intervention (PCI) vs medical therapy. However, most of the studies in prior systematic reviews used balloon angioplasty as well as medical therapies that do not reflect current interventional or medical practices. We therefore performed a meta-analysis of all randomized clinical trials comparing initial coronary stent implantation with medical therapy to determine the effect on death, nonfatal myocardial infarction (MI), unplanned revascularization, and persistent angina. Prospective randomized trials were identified by searches of the MEDLINE database from 1970 to September 2011. Trials in which stents were used in less than 50% of PCI procedures were excluded. Data were extracted from each study, and summary odds ratios (ORs) were obtained using a random effects model. Eight trials enrolling 7229 patients were identified. Three trials enrolled stable patients after MI, whereas 5 studies enrolled patients with stable angina and/or ischemia on stress testing. Mean weighted follow-up was 4.3 years. The respective event rates for death with stent implantation and medical therapy were 8.9% and 9.1% (OR, 0.98; 95% CI, 0.84-1.16); for nonfatal MI, 8.9% and 8.1% (OR, 1.12; 95% CI, 0.93-1.34); for unplanned revascularization, 21.4% and 30.7% (OR, 0.78; 95% CI, 0.57-1.06); and for persistent angina, 29% and 33% (OR, 0.80; 95% CI, 0.60-1.05). Initial stent implantation for stable CAD shows no evidence of benefit compared with initial medical therapy for prevention of death, nonfatal MI, unplanned revascularization, or angina.

Abstract P26: Depression Recognition and Disease-Specific Health Status in AMI Patients: Insights from the TRIUMPH Registry

Background: Recognizing depression in acute myocardial infarction (AMI) offers an opportunity to treat this burdensome comorbidity, and could improve the risk stratification of AMI patients. Whether depression recognition is associated with health status after AMI is unknown. Methods: In the 24-center prospective TRIUMPH study, 4062 patients completed the Patient Health Questionnaire-9 (PHQ-9) during their index AMI admission and the Seattle Angina Questionnaire (SAQ) for quality of life (QOL) and angina frequency during the index admission and at 1-year. Patients were defined as depressed based on a PHQ-9 score ≥10, and depression was defined as recognized if the treating team documented any of the following in the patients' chart: depression diagnosis at discharge; anti-depressant medications administered at discharge; or referral for counseling. We examined the association between depression recognition and impaired quality of life (SAQ QOL score &lt;75) and angina (SAQ angina frequency score &lt;100) at 1 year using multivariable Poisson regression analyses adjusted for demographics, AMI severity, risk factors, and baseline quality of life, or angina frequency, as appropriate. Results: Of 4062 patients, 3303 (81.3%) were not depressed, 528 (13.0%) had unrecognized depression, and 231 (5.7%) had recognized depression. Patients with unrecognized depression were just as likely to have increased risk of 1-year adverse QOL and angina, as compared to patients with recognized depression. (Table) Conclusion: Depression in AMI is a comorbidity that is frequently missed in routine care. Regardless of being recognized, however, depression is associated with adverse 1-year AMI-specific health status. Although depression recognition has the potential to identify patients at risk of persistent angina and poorer QOL that might benefit from more aggressive treatment of their coronary disease, recognition in itself will not be sufficient to optimize their outcomes. The Association Between Depression Recognition Groups and 1-Year Impaired Quality of Life/Angina 1-Year AMI-Specific Health Status Unadjusted Adjusted * N (%) RR (95% CI) P-Value RR (95% CI) P-Value Impaired SAQ QOL Non Depressed 369 (17.6%) Reference Reference Recognized Depression 51 (38.1%) 2.31 (1.81-2.93) &lt;.0001 1.70 (1.31-2.20) &lt;.0001 Unrecognized Depression 103 (34.4%) 1.97 (1.64-2.36) &lt;.0001 1.54 (1.32-1.80) &lt;.0001 Angina Non Depressed 436 (20.6%) Reference Reference Recognized Depression 53 (39.3%) 1.98 (1.57-2.49) &lt;.0001 1.51 (1.18-1.95) 0.046 Unrecognized Depression 97 (32.3%) 1.54 (1.31-1.80) &lt;.0001 1.32 (1.14-1.53) 0.074 Abbreviations: AMI, acute myocardial infarction; SAQ, Seattle Angina Questionnaire; QOL, quality of life. * Covariates in the multivariable model included: age, sex, race, education, marital status, insurance status, Killip class, left ventricular systolic function, chronic heart failure, diabetes mellitus, hypercholesterolemia, hypertension, prior PCI, prior CABG, prior MI, prior CVA/TIA, current smoking, BMI, family history of CAD, ST-elevation AMI, ischemic symptoms on arrival, cancer, chronic lung disease, renal failure, and peripheral arterial disease.