scholarly journals Anti-anginal drugs–beliefs and evidence: systematic review covering 50 years of medical treatment

2018 ◽  
Vol 40 (2) ◽  
pp. 190-194 ◽  
Author(s):  
Roberto Ferrari ◽  
Rita Pavasini ◽  
Paolo G Camici ◽  
Filippo Crea ◽  
Nicolas Danchin ◽  
...  
Keyword(s):  
Systematic Review ◽  
Beta Blockers ◽  
Stable Coronary Artery Disease ◽  
Chronic Stable Angina ◽  
Cochrane Collaboration ◽  
Pharmacological Therapy ◽  
Channel Blockers ◽  
Second Line ◽  
First Line ◽  
Double Blind

Abstract Chronic stable angina is the most prevalent symptom of ischaemic heart disease and its management is a priority. Current guidelines recommend pharmacological therapy with drugs classified as being first line (beta blockers, calcium channel blockers, short acting nitrates) or second line (long-acting nitrates, ivabradine, nicorandil, ranolazine, and trimetazidine). Second line drugs are indicated for patients who have contraindications to first line agents, do not tolerate them or remain symptomatic. Evidence that one drug is superior to another has been questioned. Between January and March 2018, we performed a systematic review of articles written in English over the past 50 years English-written articles in Medline and Embase following preferred reporting items and the Cochrane collaboration approach. We included double blind randomized studies comparing parallel groups on treatment of angina in patients with stable coronary artery disease, with a sample size of, at least, 100 patients (50 patients per group), with a minimum follow-up of 1 week and an outcome measured on exercise testing, duration of exercise being the preferred outcome. Thirteen studies fulfilled our criteria. Nine studies involved between 100 and 300 patients, (2818 in total) and a further four enrolled greater than 300 patients. Evidence of equivalence was demonstrated for the use of beta-blockers (atenolol), calcium antagonists (amlodipine, nifedipine), and channel inhibitor (ivabradine) in three of these studies. Taken all together, in none of the studies was there evidence that one drug was superior to another in the treatment of angina or to prolong total exercise duration. There is a paucity of data comparing the efficacy of anti-anginal agents. The little available evidence shows that no anti-anginal drug is superior to another and equivalence has been shown only for three classes of drugs. Guidelines draw conclusions not from evidence but from clinical beliefs.

Chronic stable angina

2019 ◽  
pp. 91-106
Author(s):  
Gaetano Antonio Lanza ◽  
Antonio De Vita
Keyword(s):  
Stable Angina ◽  
Myocardial Oxygen Consumption ◽  
Beta Blockers ◽  
Chronic Stable Angina ◽  
Pharmacological Therapy ◽  
Lifestyle Changes ◽  
Channel Blockers ◽  
Variable Combination ◽  
Improve Clinical Outcome ◽  
Risk Factor Burden

Treatment of patients with chronic stable angina has two main objectives: to improve clinical outcome and to reduce angina symptoms. Prognosis is mainly improved by a reduction in cardiovascular risk factor burden, which may be achieved by appropriate lifestyle changes and, for some risk factors (e.g. hypercholesterolaemia, hypertension, diabetes), appropriate pharmacological therapy (including, in particular, statins and renin–angiotensin–aldosterone system inhibitors) and use of antithrombotic agents. Symptoms can be improved by a variable combination of traditional (beta-blockers, calcium channel blockers, nitrates) and novel (e.g. ivabradine, ranolazine) anti-ischaemic drugs, which may act through reduction in myocardial oxygen consumption and/or improvement of myocardial perfusion.

scholarly journals Stable Angina Medical Therapy Management Guidelines: A Critical Review of Guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence

2019 ◽  
Vol 14 (1) ◽  
pp. 18-22 ◽  
Author(s):  
Talla A Rousan ◽  
Udho Thadani
Keyword(s):  
European Society ◽  
Stable Angina ◽  
Beta Blockers ◽  
Stable Coronary Artery Disease ◽  
Lifestyle Changes ◽  
Channel Blockers ◽  
First Line ◽  
Antianginal Drugs ◽  
European Society Of Cardiology ◽  
Randomised Controlled

Most patients with stable angina can be managed with lifestyle changes, especially smoking cessation and regular exercise, along with taking antianginal drugs. Randomised controlled trials show that antianginal drugs are equally effective and none of them reduced mortality or the risk of MI, yet guidelines prefer the use of beta-blockers and calcium channel blockers as a first-line treatment. The European Society of Cardiology guidelines for the management of stable coronary artery disease provide classes of recommendation with levels of evidence that are well defined. The National Institute for Health and Care Excellence (NICE) guidelines for the management of stable angina provide guidelines based on cost and effectiveness using the terms first-line and second-line therapy. Both guidelines recommend using low-dose aspirin and statins as disease-modifying agents. The aim of this article is to critically appraise the guidelines’ pharmacological recommendations for managing patients with stable angina.

Chronic stable angina

2019 ◽  
pp. 91-106
Author(s):  
Gaetano Antonio Lanza ◽  
Antonio De Vita
Keyword(s):  
Stable Angina ◽  
Myocardial Oxygen Consumption ◽  
Beta Blockers ◽  
Chronic Stable Angina ◽  
Pharmacological Therapy ◽  
Lifestyle Changes ◽  
Channel Blockers ◽  
Variable Combination ◽  
Improve Clinical Outcome ◽  
Risk Factor Burden

Treatment of patients with chronic stable angina has two main objectives: to improve clinical outcome and to reduce angina symptoms. Prognosis is mainly improved by a reduction in cardiovascular risk factor burden, which may be achieved by appropriate lifestyle changes and, for some risk factors (e.g. hypercholesterolaemia, hypertension, diabetes), appropriate pharmacological therapy (including, in particular, statins and renin–angiotensin–aldosterone system inhibitors) and use of antithrombotic agents. Symptoms can be improved by a variable combination of traditional (beta-blockers, calcium channel blockers, nitrates) and novel (e.g. ivabradine, ranolazine) anti-ischaemic drugs, which may act through reduction in myocardial oxygen consumption and/or improvement of myocardial perfusion.

Chronic stable angina

2019 ◽  
pp. 91-106
Author(s):  
Gaetano Antonio Lanza ◽  
Antonio De Vita
Keyword(s):  
Stable Angina ◽  
Myocardial Oxygen Consumption ◽  
Beta Blockers ◽  
Chronic Stable Angina ◽  
Pharmacological Therapy ◽  
Lifestyle Changes ◽  
Channel Blockers ◽  
Variable Combination ◽  
Improve Clinical Outcome ◽  
Risk Factor Burden

Treatment of patients with chronic stable angina has two main objectives: to improve clinical outcome and to reduce angina symptoms. Prognosis is mainly improved by a reduction in cardiovascular risk factor burden, which may be achieved by appropriate lifestyle changes and, for some risk factors (e.g. hypercholesterolaemia, hypertension, diabetes), appropriate pharmacological therapy (including, in particular, statins and renin–angiotensin–aldosterone system inhibitors) and use of antithrombotic agents. Symptoms can be improved by a variable combination of traditional (beta-blockers, calcium channel blockers, nitrates) and novel (e.g. ivabradine, ranolazine) anti-ischaemic drugs, which may act through reduction in myocardial oxygen consumption and/or improvement of myocardial perfusion.

scholarly journals Discrimination capability of pretest probability of stable coronary artery disease: a systematic review and meta-analysis suggesting how to improve validation procedures

BMJ Open ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. e047677
Author(s):  
Pierpaolo Mincarone ◽  
Antonella Bodini ◽  
Maria Rosaria Tumolo ◽  
Federico Vozzi ◽  
Silvia Rocchiccioli ◽  
...  
Keyword(s):  
Systematic Review ◽  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Quality Assessment ◽  
Meta Analysis ◽  
Stable Coronary Artery Disease ◽  
First Line ◽  
Discrimination Capability ◽  
Artery Disease

ObjectiveExternally validated pretest probability models for risk stratification of subjects with chest pain and suspected stable coronary artery disease (CAD), determined through invasive coronary angiography or coronary CT angiography, are analysed to characterise the best validation procedures in terms of discriminatory ability, predictive variables and method completeness.DesignSystematic review and meta-analysis.Data sourcesGlobal Health (Ovid), Healthstar (Ovid) and MEDLINE (Ovid) searched on 22 April 2020.Eligibility criteriaWe included studies validating pretest models for the first-line assessment of patients with chest pain and suspected stable CAD. Reasons for exclusion: acute coronary syndrome, unstable chest pain, a history of myocardial infarction or previous revascularisation; models referring to diagnostic procedures different from the usual practices of the first-line assessment; univariable models; lack of quantitative discrimination capability.MethodsEligibility screening and review were performed independently by all the authors. Disagreements were resolved by consensus among all the authors. The quality assessment of studies conforms to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). A random effects meta-analysis of area under the receiver operating characteristic curve (AUC) values for each validated model was performed.Results27 studies were included for a total of 15 models. Besides age, sex and symptom typicality, other risk factors are smoking, hypertension, diabetes mellitus and dyslipidaemia. Only one model considers genetic profile. AUC values range from 0.51 to 0.81. Significant heterogeneity (p<0.003) was found in all but two cases (p>0.12). Values of I2 >90% for most analyses and not significant meta-regression results undermined relevant interpretations. A detailed discussion of individual results was then carried out.ConclusionsWe recommend a clearer statement of endpoints, their consistent measurement both in the derivation and validation phases, more comprehensive validation analyses and the enhancement of threshold validations to assess the effects of pretest models on clinical management.PROSPERO registration numberCRD42019139388.

Treatment patterns of gastrointestinal neuroendocrine tumors (NET).

2017 ◽  
Vol 35 (4_suppl) ◽  
pp. 387-387
Author(s):  
Michael S. Broder ◽  
Eunice Chang ◽  
Beilei Cai ◽  
Maureen Neary ◽  
Elya Papoyan ◽  
...  
Keyword(s):  
Disease Status ◽  
Somatostatin Analogues ◽  
Pharmacological Therapy ◽  
Treatment Patterns ◽  
Second Line ◽  
First Line ◽  
Nccn Guidelines ◽  
First Line Therapy ◽  
Line Therapy ◽  
New Treatments

387 Background: NET comprise a broad set of rare tumors. Almost 2/3 arise in the gastrointestinal (GI) tract. NCCN guidelines for unresectable GI NET recommend somatostatin analogues (SSA) first, however, guidelines do not recommend a particular sequence for remaining therapies. Our objective is to describe real world treatment patterns of GI NET. Methods: This retrospective study combined 2 claims databases to examine newly pharmacologically treated patients using tabular and graphical techniques. Treatments included SSA, cytotoxic chemotherapy (CC), targeted therapy (TT), interferon (IF) and combinations. Patients ≥ 18 years, with ≥ 1 inpatient or ≥ 2 outpatient claims for GI NET who received pharmacologic treatment from 7/1/09-6/30/14 were identified. A 6 month clean period prior to first treatment ensured patients were newly treated. Patients were followed until end of enrollment. Results: We identified 2,258 newly treated GI NET patients. 59.6% started first line therapy with SSA monotherapy, 33.3% CC, 3.6% TT, and 0.5% IF. The remainder received combination therapies. Mean follow up was 576 days. Mean duration of first line therapy was 361 days for all newly treated patients (449 SSA, 215 CC, 267 TT). 58.9% of patients had no subsequent pharmarcological treatment after discontinuation of first line therapy.The most common second line was combination therapy with SSA (i.e., CC or TT added). In patients who did not begin with SSA, most received SSA as second line. In graphical pattern analysis, there was no clear pattern visible after first line therapy. Conclusions: More than 1/2 of pharmacologically treated patients began treatment with SSA and 1/3 with CC, with duration of use > 1 year and just over 6 months, respectively. We found treatment patterns after first line were unclear, and more than 1/2 of patients had no subsequent pharmacological treatments after discontinuing first line therapy. It is unclear whether there is underutilization of the pharmacological therapy or this is due to stable disease status after alternative non-pharmacological treatment. Future studies directed at understanding treatment patterns using patient medical records are warranted. As new treatments emerge, reassessment of treatment patterns may be needed.

Treatment of Chronic Stable Angina with Carvedilol: A Multiple-Action Neurohormonal Antagonist. A Review of Controlled Clinical Trials

1998 ◽  
Vol 26 (3) ◽  
pp. 107-119 ◽  
Author(s):  
I González Maqueda
Keyword(s):  
Stable Angina ◽  
Oxygen Free Radicals ◽  
Beta Blockers ◽  
Chronic Stable Angina ◽  
Oxygen Demand ◽  
Myocardial Oxygen Demand ◽  
Channel Blockers ◽  
Side Effect Profile ◽  
Controlled Clinical Trials ◽  
Ischaemic Damage

Beta-blockers and vasodilators, such as nitrates and calcium channel blockers, are all established antianginal therapies. These therapies have different antianginal mechanisms that dictate both their mode of action and their side-effect profile. An agent with both cardiac beta- and vascular alpha-receptor activity offers advantages over these conventional drugs. Carvedilol, a multiple-action neurohormonal antagonist, has potent antihypertensive and antianginal activity. Through its combination of pharmacological mechanisms, it reduces myocardial oxygen demand, increases myocardial blood supply and scavenges oxygen free radicals, which are capable of ischaemic damage. Studies have shown that carvedilol is at least as effective as other antianginal therapies in the management of chronic stable angina. Carvedilol is well tolerated – in several cases, the overall incidence of adverse events being lower than with other antianginal agents. These properties, combined with the documented antianginal effects, suggest that carvedilol may prove useful for the treatment of patients with chronic stable angina.

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