Relief Of Anginal Symptoms Research Articles

CORONARY-SUBCLAVIAN STEAL SYNDROME, TREATED BY BALOON-EXPANDABLE PERIPHERAL STENT. CASE REPORT

Patient K., male smoker, 65 years old, suffering from type 2 diabetes, adhering to basic therapy, in year 2018 underwent isolated internal mammary bypass surgery for coronary artery disease. In 2022, due to a deterioration in general well-being in the form of stabbing pains behind the sternum, shortness of breath during physical exertion, pain and numbness of the left upper limb, he was scheduled for coronary angiography with shuntography. During routine shuntography through the left radial access, the presence of retrograde filling of the LIMA graft was established, indicating the presence of the phenomenon of coronary-subclavian steal. Elimination of hemodynamically significant stenosis of the left subclavian artery with a peripheral balloon-expandable stent led to successful remodeling of left coronary hemodynamics, relief of angina symptoms, and restoration of adequate blood flow in the left upper limb in the early postoperative period.

Abstract 10839: Two-year Follow-up Of Patients With Chronic Ischemic Heart Disease In A Specialized Center In Brazil

Introduction: Incidence of cardiovascular events in patients with chronic ischemic heart disease (CIHD) may vary significantly between regions. Although populous, Brazil is often underrepresented in international registries. Objective: This study aimed to describe the quality of care and 2-year incidence of cardiovascular events and prognostic factors in CIHD patients in a tertiary public health care center in Brazil. Methods: Patients with CIHD, denoted as previous revascularization, myocardial infarction (MI) or stenosis > 50% in at least one epicardial coronary artery, were enrolled and followed for at least 2 years. Main endpoint was the composite of MI, stroke or death. We also evaluated prescription, symptoms and laboratory records. Results: 625 patients with mean age 65 (±9.6) years, 33.3% women, were included. Previous MI was present in 59.8%, CABG in 26.8%, and percutaneous coronary intervention in 40.6%. Diabetes was prevalent in 48.6%, high blood pressure in 83.1%, and chronic kidney disease (creatinine clearance < 60 mL/min) in 34.7%. Residual coronary anatomy was known in 266 patients, of whom 29.3% had multivessel disease, and 11.7% had lesion in the left main artery. At a median follow-up (FU) of 881 days, we recorded 37 events of primary composite endpoint, with 2-year estimate event incidence of 7.05%. Age (HR per 10 years 1.61, 95%CI 1.32-1.97), stroke (3.65, 1.48-9.00) and LDL-cholesterol (1.23, 1.14-1.33) were the main prognostic factors in multivariate analysis. The participants experienced relief of angina symptoms based on Canadian Cardiovascular Society (CCS) scale (baseline vs. FU respectively): 65.7% vs. 81.7% were asymptomatic, 13 vs. 7.2% CCS1, 17.1 vs. 8.3% CCS2, 4.2 vs. 2.9% CCS3 or 4 (p < 0.001). Analysis of therapeutic goals identified better quality of medication prescription, defined as the use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker plus statin and any antithrombotic agent: 65.8% vs. 73.6% (p<0.001) comparing baseline with FU. On the other hand, there was no improvement in LDL or blood pressure control. Conclusion: This study shows that CIHD patients had a 2-year incidence of the primary composite endpoint of 7.05%, LDL was the main modifiable risk factor of worse prognosis.

OP-052 Nicorandil Versus Nitroglycerin for Symptomatic Relief of Angina in Patients with Slow Coronary Flow Phenomenon: A Randomized Clinical Trial

OP-052 Nicorandil Versus Nitroglycerin for Symptomatic Relief of Angina in Patients with Slow Coronary Flow Phenomenon: A Randomized Clinical Trial

The Usefulness of Xuefu Zhuyu Tang for Patients with Angina Pectoris: A Meta‐Analysis and Systematic Review

Objective. To evaluate the efficacy of Xuefu Zhuyu Tang (XFZYT) for treating angina pectoris (AP). Methods. Six databases were searched (up to December, 2013). Eligible randomized controlled trials (RCTs) evaluating the efficiency of XFZYT plus traditional antianginal medications (TAMs) compared with TAMs alone in patients with AP were included. The outcomes were relief of anginal symptoms (RAS) and improvement of electrocardiogram (ECG) and blood high-density lipoprotein cholesterol (HDL-C) level. Result. Finally 14 RCTs were included. There were evidences that XFZYT combined with TAMs was more effective in improving RAS (RR = 1.29; 95% CI = [1.20, 1.38]), ECG (RR = 1.37; 95% CI = [1.22, 1.54]), and blood HDL-C level (MD = 0.29 mmol/L; 95% CI = [0.23, 0.35]) compared with TAMs alone. Our meta-analysis also showed the pooled number needed to treat (NNT) of the group with stable angina pectoris (SAP) was smaller in improving RAS (4.2 versus 5.7) and ECG (3.1 versus 5.5) compared with the group with both SAP and unstable angina pectoris (UAP). Conclusion. Combination therapy with XFZYT and TAMs is more effective in treating AP compared with TAMs alone. And XFZYT may be a more suitable choice for the treatment of SAP. However, the findings should be interpreted with caution due to the mediocre methodological quality of the included RCTs.

Acupuncture therapy for angina pectoris: a systematic review

ObjectiveTo assess the effectiveness and safety of acupuncture therapy for angina pectoris. MethodsRandomized controlled trials (RCTs) concerned with acupuncture treatment of angina pectoris were identified by searching Academic Source Premier, MEDLINE, Science Citation Index Expanded, and three Chinese databases (China biology medicine database, China national knowledge infrastructure, and VIP database for Chinese technical periodicals). The valid data were extracted in accordance with our inclusion and exclusion criteria. The main outcomes of the included studies were synthesized using Revman 5.1. ResultsTwenty-one articles on 16 individual studies were included and evaluated as having high or moderate risk of bias according to the standards of the Cochrane Collaboration. Meta-analysis indicated that acupuncture combined with conventional drugs (ACCD) was superior to conventional drugs alone in reducing the incidence of acute myocardial infarction (AMI) [OR=0.18, 95%CI (0.04, 0.84), P=0.03]. Moreover, ACCD was superior to conventional drugs in the relief of angina symptoms [OR=4.23, 95%CI (2.73, 6.56), P<0.00001], and improvement of electrocardiography (ECG) [OR=2.61, 95%CI (1.83, 3.73), P<0.00001]. Acupuncture by itself was also superior to conventional drugs for angina symptoms [OR=3.59, 95%C/(1.76, 7.92), P=0.0004] and ECG improvement [OR=3.07, 95%CI (1.54, 6.10), P=0.001]. ACCD was superior to conventional drugs in shortening the time to onset of angina relief [WMD=−1.40, 95%CI (−1.65, −1.15), P< 0.00001]. However, the time to onset was significantly longer for acupuncture treatment than for conventional treatment alone [WMD=2.43, 95%CI (1.63, 3.23), P<0.000 01]. ConclusionACCD reduced the occurrence of AMI, and both acupuncture and ACCD relieved angina symptoms and improved ECG. However, compared with conventional treatment, acupuncture showed a longer delay before its onset of action. This indicates that acupuncture is not suitable for emergency treatment of heart attack. Owing to the poor quality of the current evidence, the findings of this systematic review need to be verified by more RCTs to enhance statistical power.

40 Patient vs physician reported angina before and after revascularisation of coronary artery disease: evidence from a large randomised controlled trial (the sos trial)

IntroductionThe success of revascularisation therapies for coronary artery disease (CAD) must be measured by both an improvement in hard clinical endpoints—mortality, repeat revascularisation procedures and myocardial infarction, the traditional focus...

Metabolic Antianginal Agent Ranolazine Offers Good Symptom Relief in a Patient with Inoperable Severe Aortic Stenosis

Severe inoperable aortic stenosis is a challenge for clinicians. Management of symptoms with traditional antianginal agents, which exert hemodynamic changes often may not be possible in such patient groups. We report the first known case of the safe use of ranolazine with good symptomatic relief of angina in an 88-year-old lady with isolated severe aortic stenosis (without significant coronary disease) who was not suitable for surgical or percutaneous valve replacement due to medical comorbidity.

Is there a Failure to Optimize theRapy in anGina pEcToris (FORGET) study?

In the management of chronic stable angina, percutaneous coronary intervention (PCI) provides symptomatic relief of angina rather than improvement of prognosis. Current guidelines recommend optimization of medical therapy prior to elective PCI. It is not clear if these guidelines are adhered to in clinical practice. The aim of this multi-centre study was to determine the extent to which these treatment guidelines are being implemented in the UK. This was a multi-centre study involving six hospitals in the UK. The medical treatment and extent of risk factor modification was recorded for consecutive patients undergoing elective PCI for chronic stable angina at each site. Data collected included anti-anginal drug therapy, lipid levels and blood pressure (BP). Data on heart rate (HR) control were also collected, since this represents a fundamental part of medical anti-anginal therapy. Target HR is <60 b.p.m. for symptomatic angina. A total of 500 patients [74% male; mean age +/- SD (64.4 +/- 10.1 years)] were included. When considering secondary prevention, 85% were receiving a statin and 76% were on an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. In terms of medical anti-ischaemic therapy, 78% were receiving beta-blockers [mean equivalent dose of bisoprolol 3.1 mg (range 1.25-20 mg)], 11% a rate limiting calcium antagonist, 35% a nitrate or nicorandil and one patient was receiving ivabradine. The mean total cholesterol (95% confidence interval) was 4.3 mmol/l (4.2-4.4), mean systolic BP of 130 +/- 24 mmHg and mean diastolic BP of 69 +/- 13 mmHg. Serum cholesterol was <5 mmol/l in 77% and <4 mmol/l in 42% of the patients, 62% of the patients had systolic BP < 140 mmHg and 92% had diastolic BP < 90 mmHg. Considering European Society of Cardiology targets, 50% had systolic BP < 130 mmHg and 76% had diastolic BP < 80 mmHg. A large proportion of patients did not achieve target resting HR; 27% of patients had a resting HR of >or=70 b.p.m., 40% had a resting HR between 60 and 69 b.p.m. and 26% had a resting HR between 50 and 59 b.p.m. The resting HR was not related to the dose of beta-blocker. A significant proportion of the patients with chronic stable angina undergoing elective PCI did not achieve therapeutic targets for lipid, BP and HR control. Over 50% of patients did not receive adequate HR lowering anti-anginal therapy to achieve recommended target resting HR.

Has laser revascularization found its place yet?

Transmyocardial laser revascularization (TMR) is a relatively new therapy for atherosclerotic coronary artery disease. Unlike well established surgical and percutaneous revascularization procedures, TMR is reserved for patients with advanced and severe forms of coronary artery disease that is unsuitable for other forms of revascularization. The results of TMR so far have been controversial with a bias toward steady and incremental adoption as sole therapy or in combination with coronary artery bypass graft surgery. The controversy surrounding TMR is related to the fact that its mechanism of action is not proven beyond a reasonable doubt. It is believed that angiogensis stimulation by the laser beam may be responsible for the relief of angina. However, the marked discrepancy in the symptomatic relief of angina and the increase in myocardial perfusion is not well understood. Other mechanisms proposed include direct perfusion through the laser channels, myocardial damage, denervation of ischemic myocardium and a placebo effect. It is possible that one or more of these mechanism may be responsible at various time intervals for the relief of angina. The challenge of TMR is related to improvement in perioperative outcomes, and long-term survival without worsening of left ventricular function. The achievement of these goals makes TMR an alternative therapy to what was formerly the only therapeutic option for these patients, namely: failed maximum medical therapy.

Assessment of interlaboratory performance in the provision of perhexiline therapeutic drug monitoring services in Australia.

Perhexiline is a prophylactic antianginal agent particularly useful in patients whose angina is poorly controlled or refractory to conventional drug regimens. Although perhexiline can cause serious hepatic and neurological toxicity, maintaining trough plasma concentrations between 0.15-0.60 mg/L minimizes the risk of toxicity while providing relief of angina symptoms in a majority of patients. All pathology laboratories are required to participate in interlaboratory proficiency testing (PT) programs. The authors therefore initiated a monthly PT program to assess the performance of Australian laboratories measuring perhexiline (n = 8). PT specimens included perhexiline-spiked drug-free human plasma and pooled plasma from patients administered perhexiline. The performance of 8 Australian laboratories participating in the program was examined over a 30-month period. The mean relative standard deviation of the group was 18.2%. All centers performed well with respect to accuracy, achieving mean percentage bias within +/-8% of target perhexiline concentrations. The usefulness of the PT program was highlighted by the identification of two laboratories with an unacceptable degree of variability (up to 30% of results varied more than +/-55% from the target concentration), and the identification of potential analytical problems with the use of perhexiline metabolite concentrations for determining patients' hydroxylator status. Continued and improved use of PT by pathology laboratories is essential to ensuring the safe and effective clinical use of perhexiline.

Transmyocardial laser revascularization and angiogenesis: the potential for therapeutic benefit.

Transmyocardial laser revascularization (TMR) has emerged as a promising therapy for ischemic heart disease in patients who are not candidates for more conventional therapies such as percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Although TMR provides symptomatic relief of angina and improved cardiovascular performance in a select patient population, the mechanism by which TMR works is still a controversial issue. Recently, it has been postulated that TMR evokes an angiogenic response and thereby improves local perfusion to ischemic myocardial territories. Herein we present a review of TMR and the molecular basis of angiogenesis.

Transmyocardial Laser Revascularization

Transmyocardial laser revascularization provides a promising alternative for patients with intractable angina. The concept of blood flow directly from the left ventricular chamber into the myocardium is not a new one, and recent studies have found the potential for this application in human hearts. Laser technology has provided an avenue for exploring the possibility of revascularization through channels created in the left ventricle. Early studies have demonstrated improved relief of angina symptoms in patients who are not candidates for traditional medical and surgical revascularization modalities.

Calcium channel antagonists should be among the first-line drugs in the management of cardiovascular disease.

There are a number of cardiovascular conditions in which calcium channel antagonists (CCAs) are accepted as first-line therapy, including Prinzmetal's angina and Raynaud's phenomenon. The real issue is whether symptomatic relief of angina or effective reduction of blood pressure (BP) is matched by a good safety record. In effort angina, verapamil is as safe as metoprolol, and nifedipine (tablet form) is as safe as atenolol. In unstable angina, intravenous diltiazem is better than intravenous nitroglycerin; there are no similar data on beta-blockade. Short-acting nifedipine is contraindicated in unstable angina. There is no place for CCAs in acute phase myocardial infarction and short-acting nifedipine is contraindicated. In the post-MI phase, two specific groups of patients benefit from diltiazem or verapamil: (1) those who had non-Q-wave infarcts and (2) those who are hypertensive. The DAVIT studies argue for the safety and efficacy of verapamil but do not allow comparisons with standard beta-blocker therapy. In the treatment of hypertension, the recommendation often made that a low-dose diuretic should be first-line therapy holds for the elderly with systolic hypertension but is not based on prospective studies in the case of younger patients. High-dose diuretics may have adverse effects, as reported in two case-controlled studies. Prospective outcome data favoring beta-blocker monotherapy as first-line therapy are limited, especially in the elderly, while case-control studies suggest an increased incidence of cardiac death in those treated by beta-blockers. CCAs may be the preferred first-line antihypertensive treatment for those groups in whom low-dose diuretics are unlikely to work as monotherapy.

Results of repeat angiography up to eight years following percutaneous transluminal angioplasty.

Percutaneous transluminal coronary angioplasty (PTCA) has become a widely accepted procedure that provides acute and medium-term relief of anginal symptoms and myocardial ischaemia. The acute success rate has risen from about 50% in the early days to approximately 90% in recent years. Serial repeat angiograms obtained in different patient groups have shown a 20% incidence of angiographically defined restenosis in patients who had been successfully treated initially. Despite the restenosis, many of these patients were symptomatically improved since the lesions shown at follow-up angiography were often less severe than those that had existed prior to original PTCA. These figures suggest that a success rate of 80% at 1 year should now be a realistic expectation, especially when patients with repeat PTCA are included. None of the 87 patients re-angiographed between 2 and 8 years after successful PTCA developed restenosis after the first year of treatment. However, new stenoses of 50% or more were found in other vessel segments, in both symptomatic and asymptomatic patients, at a rate of about 7% per year.

Restenosis after multilesion percutaneous transluminal coronary angioplasty

Experience and new technical advances have resulted in an increasing number of patients with multivessel coronary disease who can be considered for percutaneous transluminal coronary angioplasty (PTCA). In selected patients with multivessel coronary disease, PTCA is a safe and effective procedure for the immediate relief of anginal symptoms. However, many questions remain regarding the long-term therapeutic benefit of the procedure. Few data are available on the incidence and clinical significance of restenosis after multilesion PTCA. Clearly, there is the potential for a higher rate of restenosis in patients who undergo dilatation of more than 1 lesion. Determination of restenosis rates after multilesion PTCA is important in the definition of expanded indications for this procedure. Because of the variations in definitions of restenosis and in patient selection factors, reported recurrence rates after multilesion PTCA are not easily compared between patient series. After multilesion dilatation the risk of developing at least 1 recurrent lesion ranges from 26% to 53% and appears to be greater than that reported for single lesion PTCA. Multilesion restenosis occurs in 7% to 21% of patients who undergo multilesion PTCA and is frequently observed in patients with recurrent symptoms. “Silent” multilesion restenosis (i.e., multiple lesion restenosis without symptoms) is rare. A higher risk of restenosis at one of several dilatation sites in a patient with extensive coronary disease should not be a deterrent in recommending multilesion PTCA to selected patients with multivessel coronary disease because the procedure provides important symptomatic relief to most. Further, recurrent narrowings are usually amenable to a second dilatation attempt if clinically indicated.

Ischaemic cardiac aneurysms and ventricular septal defects. Surgical treatment with and without revascularization.

During the period 1968--78, 35 patients with left ventricular aneurysm after acute myocardial infarction were operated on at the Department of Thoracic and Cardiovascular Surgery, University Central Hospital, Helsinki. Twenty patients underwent resection of the left ventricular aneurysm and had coronary bypass grafting (Group I) and 15 patients had aneurysmectomy without revascularization procedures (Group II). Most of the patients (21) had the operation within one year after acute myocardial infarction. The aneurysm was located in the anterior wall in 31 cases and in the posterior wall in 4 cases. Three patients in Group II had a concomitant ventricular septal rupture, which was repaired simultaneously with the aneurysmal resection. In average, the patients in Group I had bypass grafting in 1.8 coronary branches. There were no intra-operative deaths. Three patients in the revascularization group died and 2 patients in the non-revascularization group died during hospitalization (15% hospital mortality). Two patients in the revascularization group and one in the non-revascularization group died during the average follow-up time of 3.4 and 6.4 years for the respective groups (late mortality 10 and 7%). The rest of the patients were doing well, including those with repaired VSDs. Follow-up coronary angiography was carried out of 12 patients; in 10 all the grafts were patent and in 2 one revascularized coronary branch had a patent graft. Revascularization produced apparent relief of anginal symptoms. Its beneficial effects on longevity remained unestablished.