Ranolazine: a better understanding of pathophysiology and patient profile to guide treatment of chronic stable angina

Chronic stable angina pectoris, the most prevalent symptomatic manifestation of coronary artery disease, greatly impairs quality of life and is associated with an increased risk for adverse cardiovascular outcomes. Better understanding of the pathophysiologic mechanisms of myocardial ischemia permitted new therapeutic strategies to optimize the management of angina patients. Ideally, antianginal drug treatment should be tailored to individual patient’s profile and chosen according to the pathophysiology, hemodynamic profile, adverse effects, potential drug interactions and comorbidities. In this respect, and because of its peculiar mechanism of action, ranolazine represents an alternative therapeutic approach in patients with chronic stable angina and may be considered the first choice in presence of comorbidities that difficult the use of traditional therapies.

Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies

Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.

Elevated heart rate across cardiovascular continuum and its management

Elevated heart rate in both healthy individuals and patients with coronary artery disease (CAD), acute myocardial infarction (AMI) and heart failure poses a major risk factor for morbidity and mortality. This fact has further been supported by several studies pointing out to elevated resting heart rate as an important marker for this catastrophe necessitating a prompt therapeutic action plan, consisting of early detection and treatment of the risk factors, to achieve ideal heart rates (approximately 60 beats/minute) in patients which could stop or prevent the progression of the cardiovascular disease (CVD) continuum. Lowering heart rate by therapeutic interventions has shown favorable results, but most of the data so far is retrospective and limited to AMI and heart failure with beta-blocker treatment. Addition of newer drugs into the cardiac armamentarium, like ivabradine, a sinus node inhibitor acting by selective heart rate reduction, has shown several beneficial effects in a variety of conditions spanning from stable angina to heart failure. A consensus meeting was held at the national level wherein experts from various parts of the country discussed and reviewed the importance of heart rate lowering across CV continuum and addition of ivabradine for patients with chronic heart failure and chronic stable angina.

A nationwide questionnaire-based survey on practice patterns and management of chronic stable angina with a controlled release formulation of trimetazidine

Background: There is lack of real-world evidence on various aspects of chronic stable angina (CSA). Hence, a questionnaire-based survey was conducted to garner real-world data about the prevalence of CSA among Indian patients; the associated comorbidities among these patients; management practices for CSA in India; and factors affecting compliance in patients with CSA with a special focus on day and night pack for trimetazidine controlled release (CR) 35 mg BD tablets.Methods: In all, 100 health care practitioners (HCPs) who each observed 15 patients with CSA in their clinical practice participated in this quantitative, cross-sectional, questionnaire-based study. The data were collected using a structured questionnaire with 30 questions grouped into 5 sections. Data were analyzed using percentages.Results: The results from the survey showed that 52.7% HCPs had observed 31-50% of angina patients with diabetes mellitus as comorbidity. As per the questionnaire survey, 77.4% HCPs preferred trimetazidine as a second-line agent when an angina patient was not responding to beta-blockers, calcium channel blockers (CCBs), and nitrates. Furthermore, 30.1% of HCPs preferred trimetazidine CR 35 mg BD as it improved exercise tolerance as well. Results from the survey reported that 65.6% HCPs agreed with the statement that day and night packs of trimetazidine tablets help in improving patient compliance and adherence to therapy.Conclusions: Trimetazidine CR 35 mg BD appears to have a safety profile suitable for various conditions and for patients with multiple comorbidities. Trimetazidine day and night packs of tablets help in improving patient compliance and adherence to therapy.

Left Main Coronary Artery Spasm: Case Report

Vasospasm of coronary artery is a well-known cause for acute coronary syndrome (ACS) but left main coronary artery (LMCA) spasm is very rare. It may be iatrogenic or spontaneous. Here we report a case of a 44-year-old female who presented with chronic stable angina and experienced LMCA vasospasm while undergoing coronary angiography.

Intravascular ultrasound guidance to minimize the use of contrast in percutaneous coronary interventions in diabetic patients with chronic stable angina

Objective To evaluate the impact of Intravascular ultrasound guidance on the final volume of contrast agent utilized in diabetic patients undergoing PCI for chronic stable angina. Background To date, few approaches have been described to reduce the final dose of contrast agent in percutaneous coronary interventions (PCI). We hypothesized that intravascular ultrasound (IVUS) might serve as an adjuctive imaging tool in many steps during PCI, thereby reducing the use of iodine contrast. Methods A total of 100 Diabeic Egyptian patients were selected to angiography-guided PCI or IVUSguided PCI from June 2019 to January 2020 .The study type was case control and non consecutive . Both groups were treated according to a pre-defined meticulous procedural strategy. A written informed consent was taken from all patients.The primary endpoint was the total volume contrast agent used during PCI. Patients were followed clinically for an average of 6 months. Results The median total volume of contrast was 111.65 ml (interquartile range [IQR] 170.40 ± 52.91ml , range from 100 ml to 300 ml) in angiography-guided group vs. 56.99 ml (IQR 94.70 ± 19.28ml , range from 70 ml to 180 ml) in IVUS-guided group (p < 0.001).similary, the median total volume of contrast was 111.65 ml (interquartile range [IQR] 170.40 ± 52.91ml , range from 100 ml to 300 ml) in angiographyguided group vs. 56.99 ml (IQR 94.70 ± 19.28ml , range from 70 ml to 180 ml) in IVUS-guided group (p < 0.001).In-hospital and 6 month outcomes were not different between patients randomized to angiography-guided and IVUS-guided PCI according to : Death, Acute myocardial infarction, Unplanned revascularization, Stent thrombosis. Conclusions Thoughtful and extensive utilization of IVUS as the primary imaging tool to guide PCI is safe, and markedly reduces the volume of iodine contrast, compared to angiography alone guidance.