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Heart (British Cardiac Society) Mar 2020
Review
Topics: Angina Pectoris; Humans; Practice Guidelines as Topic
PubMed: 32054665
DOI: 10.1136/heartjnl-2018-314661 -
Archives of Cardiovascular Diseases Jan 2019Vasospastic angina (VSA) is a variant form of angina pectoris, in which angina occurs at rest, with transient electrocardiogram modifications and preserved exercise... (Review)
Review
Vasospastic angina (VSA) is a variant form of angina pectoris, in which angina occurs at rest, with transient electrocardiogram modifications and preserved exercise capacity. VSA can be involved in many clinical scenarios, such as stable angina, sudden cardiac death, acute coronary syndrome, arrhythmia or syncope. Coronary vasospasm is a heterogeneous phenomenon that can occur in patients with or without coronary atherosclerosis, can be focal or diffuse, and can affect epicardial or microvasculature coronary arteries. This disease remains underdiagnosed, and provocative tests are rarely performed. VSA diagnosis involves three considerations: classical clinical manifestations of VSA; documentation of myocardial ischaemia during spontaneous episodes; and demonstration of coronary artery spasm. The gold standard diagnostic approach uses invasive coronary angiography to directly image coronary spasm using acetylcholine, ergonovine or methylergonovine as the provocative stimulus. Lifestyle changes, avoidance of vasospastic agents and pharmacotherapy, such as calcium channel blockers, nitrates, statins, aspirin, alpha1-adrenergic receptor antagonists, rho-kinase inhibitors or nicorandil, could be proposed to patients with VSA. This review discusses the pathophysiology, clinical spectrum and management of VSA for clinicians, as well as diagnostic criteria and the provocative tests available for use by interventional cardiologists.
Topics: Angina Pectoris, Variant; Coronary Angiography; Coronary Vessels; Electrocardiography; Evidence-Based Medicine; Exercise Tolerance; Humans; Predictive Value of Tests; Prevalence; Prognosis; Risk Factors; Risk Reduction Behavior; Vasoconstriction; Vasodilator Agents
PubMed: 30197243
DOI: 10.1016/j.acvd.2018.08.002 -
JACC. Cardiovascular Interventions Jan 2020The aim of this study was to test the hypothesis that invasive coronary function testing at time of angiography could help stratify management of angina patients without... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
The aim of this study was to test the hypothesis that invasive coronary function testing at time of angiography could help stratify management of angina patients without obstructive coronary artery disease.
BACKGROUND
Medical therapy for angina guided by invasive coronary vascular function testing holds promise, but the longer-term effects on quality of life and clinical events are unknown among patients without obstructive disease.
METHODS
A total of 151 patients with angina with symptoms and/or signs of ischemia and no obstructive coronary artery disease were randomized to stratified medical therapy guided by an interventional diagnostic procedure versus standard care (control group with blinded interventional diagnostic procedure results). The interventional diagnostic procedure-facilitated diagnosis (microvascular angina, vasospastic angina, both, or neither) was linked to guideline-based management. Pre-specified endpoints included 1-year patient-reported outcome measures (Seattle Angina Questionnaire, quality of life [EQ-5D]) and major adverse cardiac events (all-cause mortality, myocardial infarction, unstable angina hospitalization or revascularization, heart failure hospitalization, and cerebrovascular event) at subsequent follow-up.
RESULTS
Between November 2016 and December 2017, 151 patients with ischemia and no obstructive coronary artery disease were randomized (n = 75 to the intervention group, n = 76 to the control group). At 1 year, overall angina (Seattle Angina Questionnaire summary score) improved in the intervention group by 27% (difference 13.6 units; 95% confidence interval: 7.3 to 19.9; p < 0.001). Quality of life (EQ-5D index) improved in the intervention group relative to the control group (mean difference 0.11 units [18%]; 95% confidence interval: 0.03 to 0.19; p = 0.010). After a median follow-up duration of 19 months (interquartile range: 16 to 22 months), major adverse cardiac events were similar between the groups, occurring in 9 subjects (12%) in the intervention group and 8 (11%) in the control group (p = 0.803).
CONCLUSIONS
Stratified medical therapy in patients with ischemia and no obstructive coronary artery disease leads to marked and sustained angina improvement and better quality of life at 1 year following invasive coronary angiography. (Coronary Microvascular Angina [CorMicA]; NCT03193294).
Topics: Aged; Angina Pectoris; Cardiac Catheterization; Cardiovascular Agents; Cause of Death; Clinical Decision-Making; Coronary Angiography; Disease Progression; Female; Fractional Flow Reserve, Myocardial; Humans; Male; Middle Aged; Patient Satisfaction; Predictive Value of Tests; Quality of Life; Recovery of Function; Scotland; Severity of Illness Index; Time Factors; Treatment Outcome
PubMed: 31709984
DOI: 10.1016/j.jcin.2019.11.001 -
Nature Reviews. Cardiology Feb 2018In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice... (Review)
Review
In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for traditional first-choice drugs. Considering some drugs, but not others, to be first choice is, therefore, difficult. Moreover, double or triple therapy is often needed to control angina. Patients with angina can have several comorbidities, and symptoms can result from various underlying pathophysiologies. Some agents, in addition to having antianginal effects, have properties that could be useful depending on the comorbidities present and the mechanisms of angina, but the guidelines do not provide recommendations on the optimal combinations of drugs. In this Consensus Statement, we propose an individualized approach to angina treatment, which takes into consideration the patient, their comorbidities, and the underlying mechanism of disease.
Topics: Angina Pectoris; Cardiology; Cardiovascular Agents; Clinical Decision-Making; Comorbidity; Consensus; Humans; Patient Selection; Patient-Centered Care; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 28880025
DOI: 10.1038/nrcardio.2017.131 -
Circulation Journal : Official Journal... May 2023
Topics: Humans; Coronary Vasospasm; Muscle Spasticity; Angina Pectoris, Variant; Angina Pectoris; Myocardial Ischemia; Coronary Angiography
PubMed: 36908169
DOI: 10.1253/circj.CJ-22-0779 -
Ugeskrift For Laeger Sep 2020Cardiac CT has become a frequently used diagnostic modality in Denmark, especially for the evaluation of coronary artery disease indicated by angina pectoris/dyspnoea.... (Review)
Review
Cardiac CT has become a frequently used diagnostic modality in Denmark, especially for the evaluation of coronary artery disease indicated by angina pectoris/dyspnoea. Indications have recently expanded to include evaluation of valvular heart disease, pre- and post-procedural evaluation related to several invasive procedures as well as some congenital and pediatric cardiac conditions. As described in this review, improved image quality and reduced radiation, owing to technological advances as well as a high number of well-performed scientific studies, have paved the way for this development.
Topics: Angina Pectoris; Child; Coronary Angiography; Coronary Artery Disease; Heart; Humans; Tomography, X-Ray Computed
PubMed: 33000733
DOI: No ID Found -
Expert Opinion on Pharmacotherapy Apr 2017Angina pectoris is the most prevalent symptomatic manifestation of ischemic heart disease, frequently leads to a poor quality of life, and is a major cause of medical... (Review)
Review
Angina pectoris is the most prevalent symptomatic manifestation of ischemic heart disease, frequently leads to a poor quality of life, and is a major cause of medical resource consumption. Since the early descriptions of nitrite and nitrate in the 19 century, there has been considerable advancement in the pharmacologic management of angina. Areas covered: Management of chronic angina is often challenging for clinicians. Despite introduction of several pharmacological agents in last few decades, a significant proportion of patients continue to experience symptoms (i.e., refractory angina) with subsequent disability. For the purpose of this review, we searched PubMed and Cochrane databases from inception to August 2016 for the most clinically relevant publications that guide current practice in angina therapy and its development. In this article, we briefly review the pathophysiology of angina and mechanism-based classification of current therapy. This is followed by evidence-based insight into the traditional and novel pharmacotherapeutic agents, highlighting their clinical usefulness. Expert opinion: Considering the wide array of available therapies with different mechanism efficacy and limiting factors, a personalized approach is essential, particularly for patients with refractory angina. Ongoing research with novel pharmacologic modalities is likely to provide new options for management of angina.
Topics: Angina Pectoris; Humans; Myocardial Ischemia; Quality of Life
PubMed: 28264619
DOI: 10.1080/14656566.2017.1303483 -
Expert Opinion on Investigational Drugs Dec 2016Ischemic heart disease (IHD) is a major cause of death and disability among Western countries and angina pectoris is the most prevalent symptomatic manifestation.... (Review)
Review
Ischemic heart disease (IHD) is a major cause of death and disability among Western countries and angina pectoris is the most prevalent symptomatic manifestation. Strategies to improve management of chronic stable angina are a priority. Areas covered: A comprehensive review was conducted using the Medline and Cochrane databases as well as the clinical trial databases in the United States and Europe. Traditional therapies for angina will be discussed. This review particularly emphasizes investigational therapies for angina (including pharmacological agents, cell and gene based therapies, and herbal medications). Expert opinion: There has been renewed interest in older anti-angina agents (e.g., perhexiline, amiodarone, and phosphodiestrase-5 inhibitors). Other anti-inflammatory agents (e.g., allopurinol and febuxostat) are currently undergoing evaluation for angina therapy. Therapeutic angiogenesis continues to face some challenges. Future trials should evaluate the optimum patient population that would benefit from this form of therapy.
Topics: Angina Pectoris; Angina, Stable; Cardiovascular Agents; Cell- and Tissue-Based Therapy; Drugs, Investigational; Genetic Therapy; Humans; Myocardial Ischemia
PubMed: 27791405
DOI: 10.1080/13543784.2016.1254617 -
Journal of the American College of... Jun 2020
Topics: Angina Pectoris; Fractional Flow Reserve, Myocardial; Humans; Percutaneous Coronary Intervention
PubMed: 32498807
DOI: 10.1016/j.jacc.2020.04.042 -
Pharmacology & Therapeutics Sep 2023Vasospastic angina (VSA) is characterized by episodes of rest angina that are responsive to short-acting nitrates and are attributable to coronary artery vasospasm. The... (Review)
Review
Vasospastic angina (VSA) is characterized by episodes of rest angina that are responsive to short-acting nitrates and are attributable to coronary artery vasospasm. The condition is underdiagnosed as the provocation test is rarely performed. VSA, the most important component of non-obstructive coronary artery disease, can present with angina, be asymptomatic, or can even present with fatal arrhythmias and cardiac arrest. Although most patients with VSA respond well to vasodilating medications, prognosis does not improve as expected in most patients, suggesting the existence elusive prognostic factors and pathogenesis that warrant further exploration. Moreover, patients with either severe or refractory VSA barely respond to conventional treatment and may develop life-threatening arrhythmias or suffer sudden cardiac death during ischemic attacks, which are associated with immune-inflammatory responses and have been shown to achieve remission following glucocorticoid and immunoglobulin treatments. Our recent work revealed that inflammation plays a key role in the initiation and development of coronary spasms, and that inflammatory cytokines have predictive value for diagnosis. In contrast to the existing literature, this review both summarizes the theoretical and clinical aspects of VSA, and also discusses the relationship between inflammation, especially myocarditis and VSA, in order to provide novel insights into the etiology, diagnosis, and treatment of VSA.
Topics: Humans; Coronary Vasospasm; Angina Pectoris; Coronary Artery Disease; Prognosis; Arrhythmias, Cardiac; Inflammation
PubMed: 37482097
DOI: 10.1016/j.pharmthera.2023.108500