Article

Recent advances in the management of chronic stable angina I: Approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities

The Cardiometabolic Research Institute, Houston, Texas 77054, USA.
Vascular Health and Risk Management 08/2010; 6:635-56. DOI: 10.2147/VHRM.S7564
Source: PubMed

ABSTRACT The potential importance of both prevention and personal responsibility in controlling heart disease, the leading cause of death in the USA and elsewhere, has attracted renewed attention. Coronary artery disease is preventable, using relatively simple and inexpensive lifestyle changes. The inexorable rise in the prevalence of obesity, diabetes, dyslipidemia, and hypertension, often in the risk cluster known as the metabolic syndrome, drives the ever-increasing incidence of heart disease. Population-wide improvements in personal health habits appear to be a fundamental, evidence based public health measure, yet numerous barriers prevent implementation. A common symptom in patients with coronary artery disease, classical angina refers to the typical chest pressure or discomfort that results when myocardial oxygen demand rises and coronary blood flow is reduced by fixed, atherosclerotic, obstructive lesions. Different forms of angina and diagnosis, with a short description of the significance of pain and silent ischemia, are discussed in this review. The well accepted concept of myocardial oxygen imbalance in the genesis of angina is presented with new data about clinical pathology of stable angina and acute coronary syndromes. The roles of stress electrocardiography and stress myocardial perfusion scintigraphic imaging are reviewed, along with the information these tests provide about risk and prognosis. Finally, the current status of gender disparities in heart disease is summarized. Enhanced risk stratification and identification of patients in whom procedures will meaningfully change management is an ongoing quest. Current guidelines emphasize efficient triage of patients with suspected coronary artery disease. Many experts believe the predictive value of current decision protocols for coronary artery disease still needs improvement in order to optimize outcomes, yet avoid unnecessary coronary angiograms and radiation exposure. Coronary angiography remains the gold standard in the diagnosis of coronary artery obstructive disease. Part II of this two part series will address anti-ischemic therapies, new agents, cardiovascular risk reduction, options to treat refractory angina, and revascularization.

Download full-text

Full-text

Available from: Richard Kones, Aug 28, 2015
0 Followers
 · 
112 Views
  • Source
    • "The CAD study group consists of 12 patients with stable angina pectoris (SAP), 16 with unstable angina pectoris (UAP) and 12 with acute myocardial infarction (AMI). Diagnosis of SAP and UAP were based on typical chest pain,[6] and angiographically proven CAD, while AMI patients also had increased troponin T. The control group included 10 age-matched people, whose CAG ruled out CAD, and five healthy young volunteers. Exclusion criteria included: a known history of autoimmune disease, acute or chronic infection, severe hepatic or renal dysfunction, and evidence of malignant disease. "
    [Show abstract] [Hide abstract]
    ABSTRACT: To study whether miR-214 is regulated in coronary artery disease (CAD) patients and whether placental growth factor (PLGF) is a possible target for miR-214 in atherosclerosis. Circulating miR-214 was measured by quantitative PCR using RNA isolated from 40 patients with CAD, including 12 with stable angina pectoris, 16 with unstable angina pectoris and 12 with acute myocardial infarction, and 15 controls without CAD. Plasma level of PLGF was measured by ELISA. The miR-214 level was significantly lower in CAD patients compared with that in controls (P < 0.01). Compared to controls, patients with unstable angina pectoris (UAP, 38.6±9.1 pg/mL) and acute myocardial infarction (AMI, 46.3±13.4 pg/mL) had significantly higher level of plasma PLGF, but not those with stable angina pectoris (SAP; P = 0.012, UAP vs. Control; P = 0.005, AMI vs. Control). In patients with AMI, the plasma level of miR-214 was positively correlated to that of PLGF. The results suggest that miR-214 is a beneficial microRNA for CAD patients. Loss of its protection may lead to increased PLGF levels and worsening atherosclerosis. Circulating miR-214 is a promising biomarker for alerting severe CAD.
    Journal of Geriatric Cardiology 03/2013; 10(1):34-8. DOI:10.3969/j.issn.1671-5411.2013.01.007 · 1.06 Impact Factor
  • Source
    • "Microvascular coronary heart disease, more common in females [15], often results from distinctive pathogenic mechanisms, i.e., an increased left ventricular mass in LVH, endothelial dysfunction in diabetes mellitus, increased red blood cell and platelet aggregation in dyslipidemia, and particularly, from a hereditable or acquired defect in red blood cell potassium transport and content that may impair the physiological mechanisms of instantaneous H+/K+ and O 2 /CO 2 exchanges at the myocardium capillary bed [9] [16].This group accounts for the occurrence of angina, ACS or myocardial infarction episodes despite non obstructed coronary arteries [17]. Since then, the words of the senior author, William Likoff " usual therapy of coronary artery disease was ineffective and unwarranted " in this setting, have remained unchanged in this century [2] [4] [18]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Coronary heart disease (CHD) is the leading cause of morbidity and mortality across the entire world, in which reversion of angina or improvement of ECG remains an unrealistic therapeutic option for most patients, suggesting that microvascular dysfunction or impaired oxygen delivery might be critical factors in CHD patients. This research article, thus presents the rationale basis, clinical and experimental, for the first therapeutic innovation addressing the role of red blood cell (RBC) H/K and O2/CO2 exchanges in CHD. It is followed by a randomized single-blind trial of Amiloride and Optimal Medical Therapy (OMT, n=35 cases) vs OMT alone (n=35 cases) in patients having angina, ST-T alteration and a defective RBC-K transport. All patients had serial clinical evaluation, Ion Transport Studies, ECGs and non-invasive aortic waveform and cardiovascular hemodynamic recordings. Statistical analysis was performed by SAS. Results: Amiloride rapidly improved RBC-K (84.5±4 vs 93.5±4 mmol/lc, p<0.001), angina (80% of cases, 1.5 ±0.3 weeks,CI:1.72 to 1.45), CCS Class (1.3 ±0.5 vs 3.1 ±0.8, p<0.001) vs patients with OMT alone CCS Class (3.2 ± 0.4 vs 3.3 ± 0.5, p =0.21). Reversion of angina was sustained through the next 6-months (87% vs 26 % in OMT, RR 2.1, odds ratio 6.31, Pearson χ2 34.6,p<0.0001 at 95% CI) and 1-year (85% vs 37% OMT).At 6-months of amiloride, ECG became normal (30% vs 0%, RR ∞ uncalculated-time, odds ratio ∞, Pearson χ2 42.4 at 95% CI, p<0.0001), improved (55% vs 29%; RR2.1, odds ratio 3.16, 95% CI, p<0.0001) or unchanged (15% vs 67% OMT). At 1-year, seven patients on amiloride (18%) exhibited evidence of electrical regeneration of the heart, not observed with placebo. In Conclusion: This therapeutical innovation of amiloride improves RBC H/K and O2/CO2 function, and reverses angina, ST-T alterations while inducing electrical regeneration of the heart, in patients receiving optimal medical treatment for angina. The article has short discussion on the relevant patents to the topic.
    09/2012;
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The objectives in treating angina are relief of pain and prevention of disease progression through risk reduction. Mechanisms, indications, clinical forms, doses, and side effects of the traditional antianginal agents - nitrates, β-blockers, and calcium channel blockers - are reviewed. A number of patients have contraindications or remain unrelieved from anginal discomfort with these drugs. Among newer alternatives, ranolazine, recently approved in the United States, indirectly prevents the intracellular calcium overload involved in cardiac ischemia and is a welcome addition to available treatments. None, however, are disease-modifying agents. Two options for refractory angina, enhanced external counterpulsation and spinal cord stimulation (SCS), are presented in detail. They are both well-studied and are effective means of treating at least some patients with this perplexing form of angina. Traditional modifiable risk factors for coronary artery disease (CAD) - smoking, hypertension, dyslipidemia, diabetes, and obesity - account for most of the population-attributable risk. Individual therapy of high-risk patients differs from population-wide efforts to prevent risk factors from appearing or reducing their severity, in order to lower the national burden of disease. Current American College of Cardiology/American Heart Association guidelines to lower risk in patients with chronic angina are reviewed. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial showed that in patients with stable angina, optimal medical therapy alone and percutaneous coronary intervention (PCI) with medical therapy were equal in preventing myocardial infarction and death. The integration of COURAGE results into current practice is discussed. For patients who are unstable, with very high risk, with left main coronary artery lesions, in whom medical therapy fails, and in those with acute coronary syndromes, PCI is indicated. Asymptomatic patients with CAD and those with stable angina may defer intervention without additional risk to see if they will improve on optimum medical therapy. For many patients, coronary artery bypass surgery offers the best opportunity for relieving angina, reducing the need for additional revascularization procedures and improving survival. Optimal medical therapy, percutaneous coronary intervention, and surgery are not competing therapies, but are complementary and form a continuum, each filling an important evidence-based need in modern comprehensive management.
    Vascular Health and Risk Management 09/2010; 6(1):749-74. DOI:10.2147/VHRM.S11100
Show more