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 01/2010; 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.

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    ABSTRACT: The diagnosis of transient regional myocardial ischemia (TRMI) in patients presenting with stable chest pain is a challenge. Exercise Tolerance Test (ETT) is no longer recommended in most cases due to its flaws. Alternative tests are more expensive and less readily available. The BSM Delta map is an intuitive color display of digitally subtracted ST-segment shift derived from two 80-electrode BSM recordings at baseline and at peak stress, and has shown promise as a tool for detection of TRMI. The purpose of this pilot study was to assess the feasibility of BSM Delta map as a tool to detect TRMI using dobutamine stress ECG gated single-photon emission computed tomography myocardial perfusion imaging (MPI) as a reference. Forty consecutive patients were recruited who were referred for MPI with a history of angina-like symptoms. The BSM Delta map was derived from two 80-electrode body surface mapping system recordings carried out simultaneously with MPI at (a) baseline and (b) peak dobutamine stress. Standard 12-lead ECGs were also recorded at the same time points. The mean patient age was 68±7.1years, and 52% (21/40) were female. Using MPI as the reference the sensitivity of BSM Delta map was 82% (9/11) and specificity was 86% (25/29) (95% CI 0.688-0.992), positive likelihood ratio 5.93 (95% CI 2.29-15), negative likelihood ratio 0.21 (95% CI 0.06-0.75). The sensitive of the 12-lead ECG was 36% (4/11) and specificity was 76% (22/29) (95% CI 0.356-0.767), positive likelihood ratio 1.51 (95% CI 0.55-4.15), negative likelihood ratio 0.84 (95% CI 0.51-1.37). BSM Delta map is more sensitive and specific (McNemar's chi-square test p=0.03 (95% CI, 0.448-0.924). The PPV and NPV for BSM Delta map were 69% (9/13) and 93% (25/27) respectively, compared with 36% (4/11) and 76% (22/29) for 12-lead ECG. This pilot study confirms the feasibility of using Delta map in this context and suggests that it has promising diagnostic accuracy and is superior to the 12-lead ECG. It could potentially represent a clinically suitable screening tool for TRMI in patients presenting with stable chest pain, since it is near patient and requires little specialist training for acquisition and interpretation. A larger clinical study is now required.
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    ABSTRACT: Introduction: Management of chronic angina has evolved dramatically in the last few decades with several options for pharmacotherapy outlined in various evidence-based guidelines. Areas covered: There is a growing list of drugs that are currently being investigated for treatment of chronic angina. These also include several herbal medications, which are now being scientifically evaluated as potential alternative or even adjunctive therapy for angina. Gene- and cell-based therapies have opened yet another avenue for management of chronic refractory angina in 'no-option' patients who are not candidates for either percutaneous or surgical revascularization and are on optimal medical therapy. An extensive review of literature using PUBMED, Cochrane database, clinical trial databases of the USA and European Union was done and summarized in this review. This review will attempt to discuss the traditional as well as novel therapeutic agents for angina. Expert opinion: Several pharmacological and non-pharmacological therapeutic options are now available for treatment and management of chronic refractory angina. Renewed interest in traditional therapies and cell- and gene-based modalities with targeted drug delivery systems will open the doors for personalized therapy for patients with chronic refractory angina.
    Expert Opinion on Pharmacotherapy 09/2013; · 2.86 Impact Factor
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    ABSTRACT: The introduction of the tissue-based definition of transient ischemic attack (TIA), according to which TIA may be diagnosed only in the absence of an infarction on brain neuroimaging, prompts reflections about similarities and differences between TIA and angina. Both share transitory symptoms in the absence of tissue damage, whereas stroke and myocardial infarction are associated with tissue necrosis. Apart from this, TIA and angina are widely different with respect to pathophysiology, natural history, prognosis, and response to specific medical treatments. In general terms, it could be argued that TIA differs from angina as the brain differs from the heart in structure, physiology, metabolism, and performance. Most importantly, in TIA and angina, the reversible nature of symptoms cannot be assumed as a favorable prognostic indicator. In fact, reversibility of stable angina denotes a low-risk condition, whereas in TIA and unstable angina reversibility may suggest plaque instability and relevant risk of ischemic recurrences.
    Mayo Clinic Proceedings 07/2013; 88(7):708-19. · 5.79 Impact Factor

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