Use Of Sublingual Nitroglycerin Research Articles

Enhanced External Counterpulsation Outcomes Study: Retrospective Analyses of Data Obtained from Patients at a Single Medical Center in United States.

The aim was to explore the effectiveness of enhanced external counterpulsation (EECP) therapy in patients with severe angina pectoris/ chronic heart failure symptoms, who were not suitable candidates for invasive treatment. This retrospective study employed a comprehensive methodology that includes individualized treatment, continuous monitoring, and thorough pre- and postprogram evaluations to assess the efficacy of EECP therapy. The standard protocol involved 35 one-hour treatments, with flexibility for extensions based on therapeutic progress. When pre- and posttreatment results were analyzed, EECP improved the original functional class compared with pretreatment. The mean difference in the functional class was 1.32 (0.92), p < 0.0001. Six-minute walk (6MW) distance improved from 383.6 m (110.24) to 423.1 m (121.50) with mean difference of 37.1 (44.99), p < 0.0001. Duke Activity Status Index (DASI) score improved from 3.9 (2.75) to 6.0 (4.17) with mean difference of 2.16 (3.8), p < 0.0001. Training metabolic equivalents (METs) improved from 3.0 (0.74) to 4.0 (1.57) with mean difference of 1.04 (1.2), p < 0.0001. Weekly anginal events decreased from 13.1 (13.19) to 3.2 (7.38) with mean difference of -9.78 (11.7), p < 0.0001. EECP resulted in improvement of angina pectoris functional class, the 6MW distance, reduction in the number of hospitalizations in first year posttreatment, a significant decrease in sublingual nitroglycerin use, improvement of systolic and diastolic blood pressure, and improvement of DASI score.

The Impact of Nitroglycerin on the Evaluation of Coronary Stenosis in Coronary-CT: Preliminary Study in 131 Patients.

The sublingual administration of short-acting nitroglycerin (NTG) before coronary computed tomography (CCT) improves the visualization of coronary arteries, causing vasodilatation. The aim of this study was to evaluate whether and how nitroglycerin can influence the concordance between radiologists and cardiologists in the evaluation of vessel stenosis measured in CCT by the former and during the following coronarography by the latter. We conducted a retrospective analysis of 131 patients who underwent CCT for cardiac symptoms in 2022, followed by coronarography performed six months later because of significant stenosis revealed by the CCT. First, the patients were divided into two groups: an NTG group who received sublingual nitroglycerin before CCT and a non-NTG group who did not because of contraindications. Second, 254 stenoses were measured by two radiologists after CCT and by two interventional cardiologists during the next coronarography; moreover, stenoses were classified on the basis of their location and plaque pattern (calcific, mixed and lipidic). Third, the strength of agreement was evaluated between the two radiologists, between the two cardiologists and finally between the radiologists and cardiologists in order to evaluate whether and how the interdisciplinary discrepancy in stenosis evaluation could change with or without the use of nitroglycerin before CCT and in relation to the different plaque pattern. In the NTG group, the use of nitroglycerine reduced the agreement between radiologists and cardiologists in calcific stenosis but did not change the concordance in the case of mixed or lipidic plaques on the same vessels. The use of sublingual nitroglycerin before CCT may lead to a radiological overestimation of calcific stenosis.

A Systematic Review of CD34+ Stem Cell Therapy as an Innovative and Efficient Treatment for the Management of Refractory Angina.

Despite optimal medical treatment, many individuals suffering from severe coronary artery disease are not suitable candidates for further revascularization. Therapeutic angiogenesis has attracted continuous interest to increase myocardial perfusion. Cell therapy using autologous stem cells expressing Cluster of Differentiation 34 plus (CD34+) offers a special therapeutic choice for individuals with refractory angina, seeing as CD34+ stem cells can restore microcirculation. We searched PubMed, PubMed Central (PMC), and Google Scholar to find the relevant articles to write this systematic review about the role of CD34+ stem cell therapy in the management of refractory angina. Additionally, we provided a brief explanation of CD34+ cells and their mechanism of action. Along with the positive finding of other trials, a recent open-label, single-center intracoronary CD34+ cell therapy for the treatment of coronary endothelial dysfunction in patients with angina and nonobstructive coronary arteries (IMPROvE-CED) clinical trial published in 2022 concluded improvement in coronary blood flow, a significant reduction in daily as-needed sublingual nitroglycerin use and improvement in Canadian Cardiovascular Society (CCS) angina class were observed after autologous CD34+ cell treatment. In conclusion, refractory angina management and overall prognosis may be revolutionized once this treatment is approved.

Comparative analysis of cost–effectiveness between isosorbide-5-mononitrate and isosorbide: a retrospective real-world evaluation

Aim: The cost-effectiveness of isosorbide-5-mononitrate (5-ISMN) and isosorbide dinitrate (ISDN) in real-world use in patients with coronary heart disease (CHD;either angina pectoris or myocardial infarction)was retrospectively compared. Method: In this retrospective real-world evaluation, patients with established CHD satisfying the following criteria were selected from information system of two tertiary hospitals in China: with pharmacy claiming for at least one injection of 5-ISMN or ISDN between July 2008 and May 2017; and, CHD patients. By using propensity score matching (PSM), we compared clinical aspects of efficacy, safety, length of hospital stay and cost during hospitalization between 5-ISMN and ISDN group. All data were processed by R statistical package v.2.13.1 (R Foundation for Statistical Computing, Vienna, Austria). Result: Of 5609 patients selected, 4047 received 5-ISMN and 1562 received ISDN. After PSM, we acquired 1555 pairs based on balancing of age, sex, insurance and comorbidities on admission. The frequency (4.2±6.6-times vs 6.5±9.5-times;p<0.05) and total dosage (47.5±153.4 vs 136.4±261.0mg;p<0.05) of sublingual nitroglycerin use decreased and hypotension incidence lowered (8.0 vs 13.0%;p<0.05) in 5-ISMN group compared with ISDN group. Hospital stay (16.0±11.3days vs 17.7±13.2; p<0.05) and hospitalization expenditure ([the ratio of cost in the study to the average hospitalization cost in the city] [odds ratio: 2.5 vs 2.6;p<0.05]) were reduced in 5-ISMN group as with that of ISDN group. Moreover, the main component of hospitalization cost was medical consumables and medications in both the groups. Conclusion: In the present retrospective real-world evaluation, by using PSM analysis, we found that newer injection agent of 5-ISMN was associated with fewer use of sublingual nitroglycerin, less hypotension incidence, shorter length of hospital stay and less hospitalization expenditure related to its comparator ISDN in patients with established CHD. Further evaluation and clinical experience are need in different circumference for the usage of ISDN.

Effectiveness of ranolazine in patients with type 2 diabetes mellitus and chronic stable angina according to baseline hemoglobin A1c

Ranolazine reduces the frequency of angina and use of sublingual nitroglycerin (SL NTG) in stable angina patients with type 2 diabetes (T2DM). Because pre-clinical data suggest that myocardial late sodium current (INaL), the target of ranolazine, is increased by hyperglycemia, we investigated whether the efficacy of ranolazine was influenced by glycemic control. TERISA was a multinational, randomized, double-blind trial of ranolazine vs. placebo in patients with T2DM and stable angina. Anginal episodes and SL NTG use were recorded daily in an electronic diary. Health status was evaluated at baseline and 8weeks post-randomization using the Seattle Angina Questionnaire (SAQ). The interaction between baseline HbA1c and treatment effect was tested across endpoints using analysis of covariance models, with HbA1c as a continuous variable with restricted cubic splines. The study included 913 patients, with mean age 63.6years, 39% women, mean T2DM duration 7.4years, and mean HbA1c of 7.3%. Heterogeneity of efficacy by HbA1c was observed for the primary endpoint of angina frequency (Pinteraction = .027), the key secondary endpoint of SL NTG use (Pinteraction = .030), SAQ angina frequency (Pinteraction = .001), and SAQ treatment satisfaction (Pinteraction = .025) with greater efficacy of ranolazine in those with higher HbA1c values, increasing continuously from HbA1c levels >6.5%. Among patients with T2DM and stable angina, the therapeutic benefits of ranolazine were greater in those with higher HbA1c values. These data suggest that ranolazine is particularly beneficial in patients with stable angina who have suboptimally controlled T2DM.

Coronary vasodilation by the use of sublingual nitroglycerin using 64-slice dual-source coronary computed tomography angiography

BackgroundSublingual nitroglycerin capsules or spray is routinely used to treat anginal attacks and to maximally dilate the epicardial coronary arteries during coronary angiography. These dilated coronary vessels have an advantage, but increased heart rates were disadvantageous for coronary computed tomography angiography (CTA). PurposeThe influence of applying nitroglycerin was analyzed regarding the coronary diameter, coronary luminal attenuation, evaluable number of coronary segments, heart rate (HR), HR variability, the optimal reconstruction phase, and image scoring of CTA in the same patients using a 64-slice dual-source CT. Methods and subjectsFifty-two patients with atypical chest pain underwent coronary CTA before and after the administration of sublingual nitroglycerin without heart rate control. The coronary diameter and luminal attenuation were measured on short-axial images in each coronary segment. The coronary vasodilation ratios (VRs) were calculated from the coronary diameters at the same location before and after the use of nitroglycerin. The local institutional review board approved this study and written informed consent was obtained from all the patients. ResultsNo significant differences were noted in the HR variability or optimal reconstruction phase, despite an increase in HR after the use of nitroglycerin. Nitroglycerin significantly enlarged the coronary artery diameter, and VRs of each coronary segment ranged from 7.54% to 22.26%. As compared with baseline coronary diameter, VRs of minor segments (16.91%) were significantly larger than those of major segments (11.35%), and the magnitude of VR correlated with the baseline coronary diameter (r=−0.48, p<0.001). Coronary luminal attenuation significantly increased due to additional administration of contrast material after the use of nitroglycerin (p<0.01), but no significant difference was noted in the image quality after the use of nitroglycerin. ConclusionSublingual nitroglycerin significantly enlarged the coronary diameters, especially in peripheral small coronary arteries, and increased the evaluable number of coronary segments on coronary CTA.

Evaluation of Ranolazine in Patients With Type 2 Diabetes Mellitus and Chronic Stable Angina: Results From the TERISA Randomized Clinical Trial (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina)

This study sought to examine the efficacy of ranolazine versus placebo on weekly angina frequency and sublingual nitroglycerin use in subjects with type 2 diabetes mellitus, coronary artery disease (CAD), and chronic stable angina who remain symptomatic despite treatment with up to 2 antianginal agents. Patients with diabetes have more extensive CAD than those without diabetes, and a high burden of angina. Ranolazine is not only effective in treating angina but also may improve glycemic control, thus providing several potential benefits in this high-risk group. We conducted a randomized trial to test the antianginal benefit of ranolazine in patients with diabetes and stable angina. TERISA (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina) was an international, randomized, double-blind trial of ranolazine versus placebo in patients with diabetes, CAD, and stable angina treated with 1 to 2 antianginals. After a single-blind, 4-week placebo run-in, patients were randomized to 8 weeks of double-blind ranolazine (target dose 1000 mg bid) or placebo. Anginal episodes and nitroglycerin use were recorded with daily entry into a novel electronic diary. Primary outcome was the average weekly number of anginal episodes over the last 6 weeks of the study. A total of 949 patients were randomized across 104 centers in 14 countries. Mean age was 64 years, 61% were men, mean diabetes duration was 7.5 years, and mean baseline HbA1c was 7.3%. Electronic diary data capture was 98% in both groups. Weekly angina frequency was significantly lower with ranolazine versus placebo (3.8 [95% confidence interval (CI): 3.6 to 4.1] episodes vs. 4.3 [95% CI: 4.0 to 4.5] episodes, p = 0.008), as was the weekly sublingual nitroglycerin use (1.7 [95% CI: 1.6 to 1.9] doses vs. 2.1 [95% CI: 1.9 to 2.3] doses, p = 0.003). There was no difference in the incidence of serious adverse events between groups. Among patients with diabetes and chronic angina despite treatment with up to 2 agents, ranolazine reduced angina and sublingual nitroglycerin use and was well tolerated. (Type 2 Diabetes Evaluation of Ranolazine in Subjects With Chronic Stable Angina [TERISA]; NCT01425359).

Abstract 9574: Enhanced Rho-kinase Activity in Circulating Neutrophils of Patients with Vasospastic Angina after the Great East Japan Earthquake

Purpose: We have recently demonstrated that Rho-kinase activity in circulating neutrophils is a useful biomarker for diagnosis and disease activity assessment of vasospastic angina (VSA). Coronary vasospastic activity is known to be enhanced under stressful conditions. On March 11, 2011, we experienced the Great East Japan Earthquake in our Tohoku area. In this study, we thus examined whether Rho-kinase activity was increased in VSA patients after the Earthquake. Methods: In 11 patients with proven VSA (M/F 8/3, 62±11 yrs), we were able to measure Rho-kinase activity in circulating neutrophils at 3 time points, before and 6 and 12 months after the Earthquake. Rho-kinase activity was defined by the ratio of phosphorylated form/total form of myosin-binding subunit (MBS), a substrate of Rho-kinase. We also quantitatively examined the extent of mental stress by the post-traumatic stress disorder (PTSD) questionnaire. Results: In the VSA patients, Rho-kinase activity was significantly increased at 6 months after the Earthquake despite the continued medical treatment with calcium channel blockers, which was returned to baseline level at 12 months (0.99±0.34 at baseline, 1.71±0.23 at 6 months, and 0.90±0.34 at 12 months) ( Figure ). Among the 11 patients, 3 patients were directly hit by the Tsunami, who complained increased frequency of angina attacks and the use of sublingual nitroglycerin after the Earthquake. Importantly, in those 3 patients, as compared with the remaining 8 patients without direct tsunami hit or changes in symptoms, both PTSD score (32±7 vs. 5±8, P=0.01) and the changes in Rho-kinase activity at 6 months from the baseline (268±232% vs. 55±40%, P&lt;0.05) were significantly higher. Furthermore, there was a significant correlation between the Rho-kinase activity changes and the PTSD score (r= 0.67, P&lt;0.05). Conclusions: These results indicate that Rho-kinase activity of VSA patients was transiently enhanced by the disaster-related mental stress.

Extracorporeal shockwave myocardial revascularization improves clinical symptoms and left ventricular function in patients with refractory angina

Medical therapy for refractory angina is limited and the prognosis is poor. Experimental data suggest that the use of extracorporeal shockwave myocardial revascularization (ESMR) can contribute to angiogenesis and improve symptoms of angina and left ventricular (LV) function. The objective of this study was to examine the effects of ESMR on clinical symptoms as well as LV function as assessed by cardiac MRI in patients with refractory angina. Patients with Canadian Cardiovascular Society (CCS) class III-IV angina despite medical therapy and ischemia documented on thallium or echo-dobutamine were eligible for the study. ESMR therapy was applied with a commercially available cardiac shockwave generator system under echocardiographic guidance. LV function was assessed before and 6 months after therapy by cardiac MRI. Twenty patients (four women, 16 men; mean age 64 years, range 45-83) were included in the study. The CCS class after treatment improved in all patients (16 patients angina pectoris CCS from III to II and four patients from IV to III). The use of sublingual nitroglycerin was significantly reduced as well. There was a significant improvement in LV ejection fraction as assessed by blinded MRI following therapy in the overall population (51 vs. 59%, P<0.05). This study demonstrates the potential efficacy of ESMR for the treatment of refractory angina pectoris. The patients showed both a significant clinical response as well as improved LV ejection fraction on serial MRI imaging. Larger studies are needed to adequately define the clinical utility of this novel therapy.

Frequency of sublingual nitroglycerin prescription in patients with coronary artery disease and angina and awareness of patients about the shelf life of the drug

ACC/AHA/ESC guidelines recommend sublingual nitroglycerin (SNG) in patients with stable angina pectoris and coronary artery disease (CAD). However, the shelf life of SNG following first use is six months for SNG tablets and two years for SNG sprays. We investigated the frequency of prescription of SNG tablets/sprays in patients having anginal symptoms and documented CAD and the awareness levels of patients about appropriate use of SNG. Three hundred patients (201 men, 99 women; mean age 61.7±10.8 years) with documented CAD and angina were enrolled into this study. Angina pectoris was categorized according to the functional classification system of the Canadian Cardiovascular Society. Data on cardiovascular past histories, risk factors, medications, and the use of SNG were recorded. At least one risk factor was present in 96% of the patients. Only 46% of the patients had a prescription for SNG. Of those with a prescription of SNG tablet and spray, 91.8% and 84.4% did not know the shelf life of the product, respectively. Of those who were routinely carrying SNG, 35.6% had an expired product. Of those with a prescription of SNG, only 65.9% were informed by the physician on the proper use of SNG. Our results show that, despite recommendations of the guidelines, SNG is not prescribed to a substantial percentage of patients with CAD and angina, a considerable fraction of patients carry an expired product, and that patients are not adequately informed by the physicians on the use of SNG. These problems will certainly affect the optimal medical management of CAD and its efficacy.

Noninvasive Detection of Coronary Artery Stenoses with Contrast-Enhanced Whole-Heart Coronary Magnetic Resonance Angiography at 3.0 T

Purpose: To prospectively evaluate the accuracy of contrast-enhanced whole-heart coronary magnetic resonance angiography (CMRA) at 3.0 T, with the use of sublingual nitroglycerin and abdominal banding, for assessing significant stenosis (≧50% lumen diameter reduction) in patients with suspected coronary disease, using conventional coronary artery angiography as the reference standard. Methods: We prospectively studied 71 consecutive patients with suspected coronary artery disease scheduled for conventional coronary angiography. Contrast-enhanced whole-heart CMRA was performed after sublingual nitroglycerin with an abdominal banding rolled tightly along the side of the ribs. The diagnostic performance of CMRA for the detection of significant lesions was compared with that of quantitative coronary angiography. Results: The acquisition of CMRA was completed in 67 of 71 patients, with an average imaging time of 9.6 ± 3.2 min. The average navigator efficiency was 48%. The sensitivity, specificity as well as positive and negative predictive values of whole-heart CMRA for the detection of significant lesions on a segment-by-segment analysis were 91.4, 85.8, 48.7 and 98.5%, respectively, and in a patient-based analysis 94.6, 86.7, 89.7 and 92.9%, respectively. Conclusions: Contrast-enhanced whole-heart CMRA with 3.0 T optimized by using sublingual nitroglycerin and abdominal banding methods permits reliable detection of significant obstructive coronary artery disease in patients with suspected coronary disease.

Evaluation of aggressive heart rate reduction in patients with stable angina

Background There is a strong correlation between heart rate and myocardial ischemia, cardiovascular diseases, and life expectancy in general; however, heart rate has been neglected as an important risk factor as well as a therapeutic opportunity. Purpose To investigate the effect of aggressive heart rate reduction (50 ⩽ HR ⩽ 60 bpm) on anti-ischemic and anti-anginal efficacy, left ventricular function, exercise tolerance and quality of life in patients with stable coronary artery disease with or without left ventricular dysfunction during 4 months. Methods A total of 159 patients presented with stable CAD without clinical heart failure symptoms were included in a open-label, non-comparative, prospective clinical study between June 2009 to February 2010 in King Abdul Aziz Specialist Hospital, Taif, KSA, Al Hayah National Hospital, Khamis Mushyt, KSA and Critical care department, Cairo University, Egypt. All included patients were, in addition to the ant ischemic treatment, subjected to aggressive heart rate control starting by beta blocker titrated to the maximum dose as tolerated, then Ivabradine added if the target heart rate is not achieved or rate control started by Ivabradine if beta blockers are contraindicated. Exercise treadmill test (ETT) to assess exercise capacity using time to 1 mm ST-segment depression in milliseconds, ejection fraction (EF) assessed by transthoracic echocardiography and frequency of angina attacks and the use of sublingual nitroglycerin per week during the last week were evaluated during a follow-up for 4 months. The patients were divided into two groups, group-I (patients achieved a resting heart rate between 50 and 60 bpm with heart rate reduction treatment) and group-II (patients with resting HR >60 bpm in spite of maximum treatment for heart rate reduction). Results The resting heart rate was significantly reduced from 77.98 ± 8.7 at baseline to 60.68 ± 4.34 bpm after 4 months of treatment, P < 0.001. The frequency of angina pectoris attacks had been significantly reduced from 2.14 ± 1.27 to 0.48 ± 0.58 attacks per week, P < 0.001 and the highest significant reduction was observed with group-I. Also, the frequency of use sublingual nitrate therapy was significantly reduced from 1.38 ± 1.1 tablet per week at the last week before the study to 0.12 ± 0.33 tablet per week during the last week after 4 months of treatment, P < 0.001 and the reduction was more significantly with group-I. Exercise treadmill test demonstrated statistically significant increase in the time to 1 mm ST-segment depression from 357.36 ± 66.73 at baseline to 387.96 ± 65.19 ms. after 4 months with P < 0.001. The degree of improvement was significantly higher for group-I (from 358.06 ± 68.81 at baseline to 391.71 ± 69.01 after 4 months with P < 0.001) than that of group-II (from 356.11 ± 64.8 at baseline to 381.27 ± 59.08 after 4 months with P < 0.001). Ejection fraction showed a statistically significant increase from 59.76 ± 6.86 at baseline to 61.04 ± 5.35 after 4 months with P < 0.001. Conclusion This study indicates that heart rate reduction has been associated with an improvement in quality of life in patients with stable coronary artery disease, presenting new opportunities for treatment.

130 Sublingual nitrates should be used systematically before multislices computered coronary imaging

Coronary multislices CT (MDCT) has limited spatial and temporal resolution, which hampered the analysis of coronary artery (CA) segments. By increasing CA geometry the use of nitrates before acquisition could improve analysis quality, which is heart rate (HR) highly dependant. The aim of this study was to evaluate safety, hemodynamic effects and imaging efficacy of systematic use of sublingual nitroglycerin just before a 256 slices CA scanner acquisition. Thirty six consecutive patients had a coronary MDCT acquisition after 1 spray of sublingual nitroglycerin (NatisprayR 0.30 mg) (group 1). HR and mean arterial blood pressure (MBP) were measured before and after spray. Global imaging quality assessment, number of analyzable segments according to the syntax score segmentation, mean diameter and area of each segments was done by two blinded observers and compared to a control group of 36 consecutive patients (group 2) examined with the same machine, but without nitrates. Both groups were similar considering age, sex ratio, BMI and beta-blocker used. In group 1 nitrates did not change heart rate (62 ± 5 vs. 61 ± 4 bpm) nor MBP (100.7 ± 15 mmHg vs. 94.9 ± 12 mmHg). A total of 536 and 531 segments were analyzed respectively in group 1 and 2. Global imaging quality assessment was equal in both groups (good quality: 93.1% vs. 91.7%, group 1 and 2 respectively). There was <1% of missed segments in group 1 compared to 3% in group 2 (p = 0.002), this represents 2.1% vs. 7.2% of secondary segments, p = 0.03. Per segments mean diameter and area was greater in group 1 than group 2 (3.2 mm ± 0.1 vs. 2.8 mm ± 0.1, p < 0.0001; 8.6 mm 2 ± 0.3 vs. 6.2 mm 2 ± 0.3, p < 0.0001). Sublingual nitroglycerin significantly improves CA geometry and number of assessable segments, especially in smaller secondary segments, with no quality deterioration. Thus, sublingual nitrates should be systematically used before a coronary MDCT.

Sublingual Nitroglycerin Practices in Patients With Coronary Artery Disease in Australia

Sublingual nitroglycerin (SLNTG) medications are a recommended treatment for people with coronary artery disease (CAD); however, prescription and knowledge may be suboptimal. This study set out to determine how often SLNTG is prescribed and the knowledge and factors associated in patients with CAD. Patients (n = 142) were recruited from cardiac rehabilitation and surveyed regarding SLNTG prescription and key knowledge areas related to SLNTG in those prescribed (n = 89). Multiple regression analysis was used to determine independent predictors of knowledge. Despite having CAD, 37% were not prescribed SLNTG, and of those prescribed, only 43% received related instruction. Knowledge of SLNTG was low at a mean 7.11 (SD, 2.05) points of a possible 14. Most participants (96%) knew to use SLNTG to treat chest pain/discomfort, and no participant described inappropriate symptoms for treatment. Although most patients (80%) knew to have the SLNTG available at all times, only 46% did so in reality. One in 5 participants reported that they would not call an ambulance if chest pain was unrelieved by SLNTG. Participants had more SLNTG knowledge if they were married, were male, and had been instructed about SLNTG and had less knowledge if their hospital discharge diagnosis included angina. The reporting of calling an ambulance for unrelieved symptoms was increased by having more knowledge of SLNTG, but decreased if participants had prior use of SLNTG, were married, or had more comorbidities. Consideration of prescription for SLNTG and related instruction, particularly for their chest-pain action plan, needs to be provided more systematically for patients with CAD.

Traditional Management of Chronic Stable Angina

The clinical syndrome of chronic stable angina is an age-related condition that is one common manifestation of coronary artery disease (CAD). The presence of angina significantly affects quality of life when patients must limit their activities of daily living in an effort to prevent the occurrence of anginal attacks. In addition, patients are at risk for significant complications of CAD such as myocardial infarction, heart failure, stroke, and death. Therefore, treatment should focus not only on relief of symptoms and improvements in quality of life, but also on preventing disease progression and reducing the risk of complications from CAD. All patients should be instructed on the appropriate use of sublingual nitroglycerin for the immediate treatment of anginal episodes. Beta-blockers, calcium channel blockers, long-acting nitrate therapy, and ranolazine can prevent anginal symptoms. In addition, aggressive risk factor management, healthy lifestyle changes, antiplatelet agents such as aspirin, and angiotensin-converting enzyme inhibitors all should be used to prevent disease progression and occurrence of myocardial infarction or death. Many patients will be candidates for revascularization of the myocardium with either percutaneous coronary intervention or coronary artery bypass grafting for relief of symptoms as well as improvement in prognosis. Even after revascularization, patients may still require antianginal drug therapy. All patients undergoing revascularization should be guided to make appropriate lifestyle changes and to make concerted efforts to manage risk factors for CAD.

Changes in the Numeric Descriptive Scale for Pain After Sublingual Nitroglycerin Do Not Predict Cardiac Etiology of Chest Pain

We determine whether the change in numeric descriptive scale for pain after sublingual nitroglycerin use can predict cardiac etiology of chest pain. A prospective study of a convenience sample of patients who had chest pain, presented to the emergency department from May 24, 2001, to April 30, 2002, and received sublingual nitroglycerin during their evaluation was performed. The 11-point numeric descriptive scale for chest pain was recorded before and after the initial dose of sublingual nitroglycerin. Cardiac-related pain was defined as chest pain in a patient with a discharge diagnosis of myocardial infarction or the diagnosis of coronary artery disease based on a positive diagnostic study (cardiac catheterization or noninvasive stress imaging). Change in the numeric descriptive scale was divided into 4 categories: (1) significant/complete reduction; (2) moderate reduction; (3) minimal reduction; and (4) no change. The study cohort was composed of 664 patients: 345 women (52%) and 319 men (48%), mean age 52 years (+/-12.4 years). Cardiac-related chest pain was identified in 122 patients (18%). In the overall patient population, 125 (19%) patients had no change in pain, 206 (31%) patients had minimal reduction, 145 (22%) patients had moderate reduction, and 188 (28%) patients had significant or complete reduction in pain. There was no significant difference in any subgroup of numeric descriptive scale response to sublingual nitroglycerin administration in patients with and without a diagnosis of cardiac chest pain. In this convenience sample, the response of chest pain to sublingual nitroglycerin was not a reliable indicator of a cardiac etiology.

Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting

Study Question: Is the treatment and prevention of stable symptomatic angina pectoris by primary care physicians in VA hospital clinics consistent with good medical practice? Methods: A cross-sectional analysis was conducted in 7038 veterans with self-reported coronary heart disease who completed the Seattle Angina Questionnaire (SAQ) and who had made a primary care visit to one of seven VA general internal medicine clinics between May 1997 and January 2000. The main outcome measures included the anginal frequency scale of the SAQ and receipt of prescriptions of appropriate dosing for antianginal medication in three classes (beta-blockers, calcium antagonists, and long-acting nitrates). Effective treatment was defined as a SAQ score of ≥70 representing angina or use of sublingual nitroglycerin ≤2 times per week. Results: Mean age was 66 years, 98% were male, and coded diagnosis included 74% with angina, 51% a previous MI, 45% previous coronary revascularization, 70% hypertension, 27% COPD, and 22% smokers. Seventy percent of the patients with angina by the SAQ were considered adequately treated. Of the 30% of patients with more frequent symptoms, 22% were receiving no antianginal medications and 33% were receiving only one class of antianginal medication. Of the patients with frequent angina who were prescribed medications, 18% were taking no medications at the recommended therapeutic dose and 50% were receiving only one class of antianginal medication at the recommended therapeutic dose. Using multivariate analysis, the presence of CHF, COPD, GERD, joint pains, a previous stroke, and post-traumatic stress disorder were associated with a lower likelihood of successful treatment of angina. There was no difference in treatment outcome by provider type (attending, fellow, resident, PA, NP, etc.). Conclusions: A substantial proportion of patients with frequent episodes of chronic stable angina appeared to be receiving an inadequate antianginal regimen in terms of number of agents and dosages in the VA hospital clinics. Perspective: The Seattle Anginal Questionnaire is a well validated tool for assessing therapeutic interventions in angina. It may not be an appropriate tool for assessing treatment appropriateness in patients without a clinical diagnosis of angina, and in whom concurrent diagnosis may be confused with angina. Nevertheless, it is refreshing that a healthcare system is willing to report the magnitude of undertreatment of cardiovascular symptoms. It would be interesting to assess the relationship between treatment of symptoms and appropriateness of treatment of coronary risk factors. MR

The psychometric properties of four quality of life instruments used in cardiovascular populations.

The psychometric properties of four quality of life instruments used in cardiovascular populations.

Patient awareness of correct sublingual nitroglycerin use unsatisfactory

Patient awareness of correct sublingual nitroglycerin use unsatisfactory

Quality of life of chronic stable angina patients 4 years after coronary angioplasty or coronary artery bypass surgery.

To evaluate the quality of life experienced by chronic stable angina patients with one- or two-vessel coronary artery disease treated with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). Prospective survey and review of medical records. Consecutive series of 601 Swedish chronic stable angina patients with one- or two-vessel disease who underwent CABG (n = 252) or PTCA (n = 349) between May 1994 and January 1995. We assessed five components of the Swedish Quality of Life Survey, anginal frequency, sublingual nitroglycerin use, and survival at 6, 21 and 48 months following coronary revascularization. Anginal frequency and sublingual nitroglycerin use decreased for all patients by 6 months, but more amongst surgery patients than amongst angioplasty patients (P < 0.05). At 48 months, more bypass patients reported that they had not used sublingual nitroglycerin during the preceding 4 weeks (73.1 vs. 63.4%, P < 0.05). At 6 months, bypass patients had greater levels of improvement in physical functioning (15.3 vs. 10.5, P < 0.05) and general health perception (16.5 vs. 10.2, P < 0.05) than angioplasty patients. Bypass patients also had better relief from pain (19.4 vs. 14.6, P < 0.05), quality of sleep (17.6 vs. 4.6, P < 0.05) and general health perception (17.3 vs. 12.1, P < 0.05) at 21 months. By 48 months follow-up, there was no longer any difference in these measures between groups. Both bypass surgery and angioplasty lead to improved quality of life for patients with chronic stable angina and one- or two-vessel coronary artery disease. Bypass surgery is associated with better quality of life at 6 months, but by 48 months quality of life is similar for patients initially treated by either procedure.