Diagnosis and Management of Stable Angina: A Review

Ranolazine effects on exercise tolerance and angina frequency in Taiwanese stable angina: A bridging study of the CARISA randomized trial

BACKGROUND

The effectiveness of Ranolazine on chronic angina had been proved and launched in the United States. This study aimed to determine whether add-on Ranolazine could also be effective in Taiwanese population with persisting angina symptoms despite taking conventional antianginal agents.

METHODS

This is a multi-center, randomized, parallel, double-blind comparative study. The endpoint is to compare the change from the baseline of the exercise treadmill test (ETT) performing duration between add-on ranolazine and placebo at week 12.

RESULTS

46 patients were evaluable for the efficacy and safety endpoints. The mean change from baseline in ETT duration at week 12 was increased in the treatment and control group, and their mean difference was 20.8 s. All data in the Taiwanese population was like those in the CARISA study (24.0 s). The safety evaluation revealed that patients were tolerable to the add-on ranolazine therapy. The AE incidence for both ranolazine and placebo was 34.8%. The data were comparable to the past studies despite the limited statistical power.

CONCLUSION

The add-on ranolazine therapy shows the potential to raise the exercise performance and tolerance of patients with chronic angina.

Efficacy and Safety of Suxiao Jiuxin Pills in the Treatment of Chronic Coronary Syndrome with Intolerance to Adverse Effects of Long-acting Nitrates: A Multicenter, Randomized, Double-blind, Placebo-controlled Study

BACKGROUND

This study aims to investigate the short-term effects and safety of adjunct Suxiao Jiuxin Pills (SJPs) on conventional therapy in chronic coronary syndrome (CCS) patients who are intolerant to the adverse effects of long-acting nitrates.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled trial. A total of 174 CCS participants from eight clinical study centers in China were included in the modified intention-to-treat analyses. Participants with CCS and intolerance to the adverse effects of long-acting nitrates were recruited and randomized to either the SJPs or the placebo group for a duration of 4 weeks.

RESULTS

Compared to the placebo group, the SJPs group showed a significant improvement in the efficacy rate after 4 weeks (OR = 2.43, 95% CI = 1.32 to 4.47, P = 0.004). Besides, individuals without a history of alcohol consumption showed a greater improvement in the SAQ summary score compared to those with a history of alcohol consumption.

CONCLUSION

Adjunctive SJPs enhance the effectiveness of short-term conventional anti-angina treatment for patients with CCS who experience intolerance to long-acting nitrates, without significant adverse effects during application.

TRIAL REGISTRATION

Chinese Clinical Trials Registry Platform, ChiCTR2100050066. Registered 16 August 2021, https://www.chictr.org.cn/showproj.html?proj=131470 .

Relative uteroplacental insufficiency of labor

Relative uteroplacental insufficiency of labor (RUPI-L) is a clinical condition that refers to alterations in the fetal oxygen "demand-supply" equation caused by the onset of regular uterine activity. The term RUPI-L indicates a condition of "relative" uteroplacental insufficiency which is relative to a specific stressful circumstance, such as the onset of regular uterine activity. RUPI-L may be more prevalent in fetuses in which the ratio between the fetal oxygen supply and demand is already slightly reduced, such as in cases of subclinical placental insufficiency, post-term pregnancies, gestational diabetes, and other similar conditions. Prior to the onset of regular uterine activity, fetuses with a RUPI-L may present with normal features on the cardiotocography. However, with the onset of uterine contractions, these fetuses start to manifest abnormal fetal heart rate patterns which reflect the attempt to maintain adequate perfusion to essential central organs during episodes of transient reduction in oxygenation. If labor is allowed to continue without an appropriate intervention, progressively more frequent, and stronger uterine contractions may result in a rapid deterioration of the fetal oxygenation leading to hypoxia and acidosis. In this Commentary, we introduce the term relative uteroplacental insufficiency of labor and highlight the pathophysiology, as well as the common features observed in the fetal heart rate tracing and clinical implications.

White blood cell counts can predict 4-year cardiovascular disease risk in patients with stable coronary heart disease: a prospective cohort study

Background

The prevalence of cardiovascular disease has increased sharply in the Asian population, and evaluation of the risk of cardiovascular events with stable coronary heart disease remains challenging. The role of white blood cell (WBC) count in assisting clinical decision-making in this setting is still unclear.

Objectives

This study sought to evaluate the prognostic meaning of WBC count among patients with stable coronary heart disease.

Methods

This study included Asian participants (n = 1,933) from the prospective STABILITY (Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy) trial, which involved 15,828 patients with stable coronary heart disease with 3-5 years of follow-up on optimal secondary preventive treatment. WBC count was measured at baseline. Associations between WBC count and cardiovascular outcomes were evaluated by Cox regression analyses with multivariable adjustments. Hematologic emergencies in patients may introduce potential bias.

Results

In the lower WBC count quartiles, patients had lower-risk clinical profiles. Higher WBC counts were associated with greater event probabilities for cardiovascular death, major cardiovascular events, or all-cause death. In Cox regression models, WBC counts were an independent predictor of major adverse cardiovascular events (OR = 2.445, 95% CI 1.427-4.190, P = 0.001) for the primary outcomes. For the secondary outcomes, including the composite of all-cause death, cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure, WBC counts were significantly predictive of events with similar magnitude (OR = 1.716, 95% CI 1.169-2.521, P = 0.006).

Conclusions

In patients with stable coronary heart disease, higher WBC counts were associated with a heightened risk for the primary or secondary outcomes.

Registration

https://clinicaltrials.gov/; Unique identifier NCT00799903.

Association of baseline serum sodium with long-term outcomes in newly diagnosed coronary heart disease patients without heart failure: a prospective cohort study

Sodium is crucial for maintaining cardiovascular health, especially in relation to heart failure. The impact of baseline serum sodium concentrations on the outcomes of newly diagnosed coronary heart disease (CHD) without heart failure remains unclear. This prospective cohort study included 681 patients who were newly diagnosed with CHD. Cox proportional hazards models and restricted cubic spline (RCS) analysis were used to assess the relationship between serum sodium concentrations and major adverse cardiovascular events. The improvement in traditional prediction models by the addition of serum sodium concentrations was assessed using changes in the C-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). During a median follow-up of 51.04 months (IQR: 40.88-53.80 months), 131 events were recorded. Multivariate Cox proportional hazards models showed that the L2 group (136-138.9 mmol/L) had the highest MACE risk. Compared to L2, the hazard ratios (HRs) and 95% confidence intervals (CIs) for the L1 (130-135.9 mmol/L), L3 (139-140.9 mmol/L), L4 (141-142.9 mmol/L), and L5 (143-147.0 mmol/L) groups were 0.31 (0.14-0.70, P = 0.005), 0.48 (030-0.78, P = 0.003), 0.56 (0.34-0.92, P = 0.022), and 0.37 (0.22-0.64, P < 0.001), respectively. Including serum sodium concentrations in the prediction model significantly improved the C-statistic from 0.647 to 0.679 (P = 0.022), with an NRI of 0.338 (P < 0.001) and an IDI of 0.026 (P < 0.001). RCS analysis showed a nonlinear relationship: within the 130-138 mmol/L sodium range, MACE risk gradually increased with higher sodium levels (HR 1.39, 95% CI 1.09-1.76, P = 0.008); whereas within the 138-147 mmol/L range, the risk gradually decreased (HR 0.88, 95% CI 0.80-0.98, P = 0.014). Baseline serum sodium concentrations are significantly associated with long-term cardiovascular risk in newly diagnosed CHD patients, showing an inverted U-shaped relationship, whereas low serum sodium may be specifically linked to higher risks of death and nonfatal myocardial infarction. Further research is needed to explore the impact of long-term changes in serum sodium concentrations on disease prognosis.

Morphological Changes of Peri-Coronary Adipose Tissue Together with Elevated NLR in Acute Myocardial Infarction Patients in-Hospital

Background

Inflammation triggers atherosclerotic plaque rupture, leading to acute myocardial infarction (AMI). Following AMI, peri-coronary adipose tissue (PCAT) undergoes a transition from lipid-rich to hydrophilic characteristics due to vascular inflammation. This study investigates PCAT changes and neutrophil-to-lymphocyte ratio levels during AMI.

Patients and Methods

60 AMI patients undergoing coronary computed tomography angiography and angiography (Jan 2020-Jun 2022) were studied 60 age, gender, BMI-matched stable angina, and 60 non-coronary artery disease patients were included. Siemens VB20.0 measured PCAT-volume and fat attenuation index (FAI). Neutrophil-to-lymphocyte ratio levels were calculated by peripheral blood tests.

Results

The PCAT volume and PCAT-FAI gradually increased across the control, stable angina, and AMI groups, with a corresponding gradual rise in NLR. NLR exhibited weak positive correlation with PCAT-FAI (r=0.35) and PCAT-volume (r=0.24). Multivariable logistic regression identified increased PCAT-volume, PCAT-FAI and neutrophil-to-lymphocyte ratio as possible independent AMI risk factors. No significant PCAT-volume difference was observed between infarct-related artery (IRA) and non-IRA for all three coronary arteries. Only PCAT-FAI around IRA-LAD was higher than non-IRA-LAD (-74.84±6.93 HU vs -79.04±8.68 HU). PCAT-FAI around culprit vessels in AMI was higher than corresponding lesion related vessel in SA. PCAT-volume around narrowed non-IRA in AMI was higher than that of corresponding LRV in SA. PCAT-FAI of narrowed non-IRA-LADs and non-IRA-LCXs in AMI were elevated compared to LADs (-78.46±8.56HU vs -83.13±8.34 HU) and LCXs (-73.83±10.63 HU vs -81.38±7.88 HU) of lesion related vessel in stable angina.

Conclusion

We found an association between AMI and inflammation in the coronary perivascular adipose tissue and systemic inflammatory response.

A novel radiomics-based technique for identifying vulnerable coronary plaques: a follow-up study

BACKGROUND

Previous reports have suggested that coronary computed tomography angiography (CCTA)-based radiomics analysis is a potentially helpful tool for assessing vulnerable plaques. We aimed to investigate whether coronary radiomic analysis of CCTA images could identify vulnerable plaques in patients with stable angina pectoris.

METHODS

This retrospective study included patients initially diagnosed with stable angina pectoris. Patients were randomly divided into either the training or test dataset at an 8 : 2 ratio. Radiomics features were extracted from CCTA images. Radiomics models for predicting vulnerable plaques were developed using the support vector machine (SVM) algorithm. The model performance was assessed using the area under the curve (AUC); the accuracy, sensitivity, and specificity were calculated to compare the diagnostic performance using the two cohorts.

RESULTS

A total of 158 patients were included in the analysis. The SVM radiomics model performed well in predicting vulnerable plaques, with AUC values of 0.977 and 0.875 for the training and test cohorts, respectively. With optimal cutoff values, the radiomics model showed accuracies of 0.91 and 0.882 in the training and test cohorts, respectively.

CONCLUSION

Although further larger population studies are necessary, this novel CCTA radiomics model may identify vulnerable plaques in patients with stable angina pectoris.

The clinical value of β-blockers in patients with stable angina

Stable angina, one manifestation of chronic coronary syndrome (CCS), is characterised by intermittent episodes of insufficient blood supply to the myocardium, provoking symptoms of myocardial ischaemia, particularly chest pain. These attacks usually occur during exercise or stress. Anti-ischaemic drugs are the mainstay of pharmacologic management of CCS with symptoms of angina. β-blockers reduce heart rate and myocardial contractility, thus reducing myocardial oxygen consumption. These drugs have been shown to ameliorate the frequency of anginal attacks and to improve exercise capacity in these patients. Current management guidelines include β-blockers as a first-line management option for most patients with CCS and symptoms of myocardial ischaemia, alongside dihydropyridine calcium channel blockers (CCB). The presence of comorbid angina and heart failure is a strong indication for starting with a β-blocker. β-blockers are also useful in the management of angina symptoms accompanied by a high heart rate, hypertension (with or without a renin-angiotensin-aldosterone-system [RAS] blocker or CCB), or microvascular angina (with a RAS blocker and a statin). A β-blocker is not suitable for a patient with low heart rate (<50 bpm), although use of a β-blocker may be supported by a pacemaker if the β-blocker is strongly indicated) and should be used at a low dose only in patients with low blood pressure.

Efficacy and safety evaluation of Ginkgo biloba dropping pill (GBDP) on stable angina pectoris complicated with depression: A placebo-controlled, randomized, double-blind, multicenter study

BACKGROUND

Stable angina pectoris (SAP) is a clinical condition characterized by reversible and temporary myocardial ischemia and hypoxia. A majority of SAP patients also experience depressive disorders, which adversely affect their disease prognosis and overall quality of life. However, the clinical utility of existing antidepressants is constrained by their side effects. Ginkgo biloba dropping pill (GBDP), a Chinese patented medication, has demonstrated efficacy in the treatment of both coronary heart disease and mental disorders. This prospective, randomized, double-blind, multicenter clinical trial aimed to assess the effectiveness and safety of GBDP as an adjuvant therapy for SAP complicated by depression.

METHODS

Participants were randomly assigned in a 1:1 ratio to receive either GBDP or a placebo (5 pills, three times a day) in addition to standard therapy for a duration of 12 weeks. The Seattle Angina Questionnaire (SAQ) was administered every 4 weeks during the treatment, and angina event frequency was assessed weekly. The 36-item Short-Form (SF-36) and Hamilton Depression Scale (HAMD) scores were measured both before and after the treatment.

RESULTS

Out of the 72 patients, 68 (n = 34 per group) completed the entire study. At the first visit (4 weeks ± 3 days), the SAQ-Angina Stability score in the GBDP group was significantly higher than that in the placebo group (p < 0.05). While the average weekly frequency of angina episodes in the placebo group notably increased after 12 weeks of treatment (p < 0.05), it displayed an improving trend in the GBDP group (p > 0.05). By the endpoint, each subcategory score of SF-36 in the GBDP group exhibited significant improvement compared to baseline (p < 0.05). The comparison of score improvement between the two groups revealed that the SF-PCS score of the GBDP group was higher than that of the placebo group (p < 0.05). HAMD scores in both groups significantly increased after treatment (p < 0.05). No discernible difference in the incidence of adverse reactions was observed between the two groups (p > 0.05).

CONCLUSION

In patients with SAP complicated by depression, GBDP, when combined with standard treatment, rapidly and safely alleviates angina pectoris symptoms. It demonstrates therapeutic potential in enhancing the quality of life and alleviating depressive symptoms.

Combined Serum Albumin and Left Ventricular Ejection Fraction Predict All-Cause Death in Patients with Stable Coronary Artery Disease

Objective

To explore the feasibility of serum albumin (Alb) and left ventricular ejection fraction (LVEF) in predicting all-cause death (ACD) in patients with stable coronary artery disease (SCAD).

Methods

Patients with SCAD were divided into 4 groups according to their Alb and LVEF levels: Group A: Alb ≤4 g/dL and LVEF > 50%; Group B: Alb ≤4 g/dL and LVEF ≤50%; Group C: Alb >4 g/dL and LVEF ≤50%; Group D: Alb >4 g/dL and LVEF >50%. The K-M curve and log-rank test were used to compare ACD among the four groups over three years. Receiver operating characteristic (ROC) curves were used to compare the efficacy of predicting ACD among the combination of Alb and LVEF and either Alb or LVEF alone. Cox regression analysis identified the influencing factors of ACD in patients with SCAD and detected the correlation between Alb and LVEF.

Results

ACD occurred in 18 (8.9%) of 203 patients with SCAD, with an average follow-up of 26.53 ± 14.34 months. In the Kaplan‒Meier analysis, the risk of ACD in the four groups ranged from high to low: Group B (17.6%) > Group A (26.7%) > Group D (0.9%) > Group C (0%, P < 0.001). The ROC curve showed that the combination of Alb and LVEF (AUC = 0.888) had better predictive value for ACD than either Alb (AUC = 0.879) or LVEF alone (AUC = 0.651), P < 0.001. Multivariate Cox regression analysis showed that Alb ≤4 g/dL predicted ACD events after adjusting for baseline (HR: 12.16, 95% CI: 1.57 to 94.41; P=0.017) and treatment (HR: 19.36, 95% CI: 2.53-147.78, P=0.004). Alb was positively correlated with LVEF (r = 0.22, P=0.002).

Conclusions

Alb combined with LVEF is more effective than a single index in predicting ACD in SCAD and could be used as a new model to judge the prognosis of SCAD.

Anatomical Ignorance Resulting in Iatrogenic Causes of Human Morbidity

This article discusses how inadequate anatomy education contributes to iatrogenic causes of human morbidity and mortality. Through a review of the relevant literature, high-yield clinical cases were identified in which a lack of sufficient anatomical knowledge contributed to patient morbidity, such as abscess formation and neuropathy as a result of improper intramuscular injections, superior gluteal nerve injuries due to surgical procedures, and misdiagnoses due to physicians' inability to examine and correlate clinical and radiological findings. The importance of a multimodal learning approach in anatomy education for medical students, which includes the utilization of the cadaveric dissection approach to emphasize spatial understanding, is crucial for the development of competent physicians with a deep-rooted foundational knowledge of anatomy and related concepts, such as physiology, pathology, and radiology. It cannot be understated that anatomy education and a lack of knowledge of anatomy and related concepts may influence iatrogenic causes of human morbidity and mortality. Therefore, all efforts should be made to ensure that students develop a strong foundational anatomy knowledge during their preclinical years.

Evaluation of the efficacy and safety of Suxiao Jiuxin Pill in the treatment of stable angina: A randomized, double-blind, placebo-controlled, multi-center clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

The Suxiao Jiuxin Pill (SJP) has been used for treating chronic stable angina (SA) for more than 40 years in China. SJP is composed of two Chinese herbs and has the effect of activating blood and promoting qi, according to traditional Chinese medicine (TCM) theory.

AIM OF THE STUDY

The study aims to determine the effects of adjunct SJP on conventional therapy in patients with SA which provides a complementary choice and its evidence for clinical medication for treating SA.

MATERIALS AND METHODS

Participants with SA were recruited and randomized 1:1 to either the SJP group or the control group for 24 weeks. Both groups received conventional treatment according to local tertiary hospital protocols, and the participants received additional SJP (composed of Ligusticum wallichii and Borneol) or placebo in treatment and control groups respectively. The primary outcome was the curative efficacy rate at week 4. Secondary outcomes are the curative efficacy rate, the total score of angina pectoris symptoms, CCS Angina Classification improvement, Seattle Angina Questionnaire (SAQ) score, TCM syndrome scores (TCMSS), and the curative efficacy rate of TCMSS. Adverse events and adverse drug reactions were observed and recorded for safety analysis.

RESULTS

A total of 324 participants with SA from 13 hospitals in China were enrolled in this trial. Compared with the control group, the curative efficacy rate of SA, the curative efficacy rate of TCMSS significantly increased, and the total score of angina pectoris symptoms and TCMSS significantly reduced in the SJP group at week 4, 12, and 24, accompanied by the statistically significant improvement in the curative efficacy rate based on CCS grade reduction (all P < 0.05). Furthermore, the SAQ score (physical limitation, angina stability, and treatment satisfaction) was evaluated as the quality of life significantly improved after treatment (P < 0.05). The medication compliance, concomitant medication, and rates of adverse events were similar between the two groups (P > 0.05).

CONCLUSION

The present prospective, multicenter, randomized, double-blind, placebo-controlled, clinical trial confirms that adjunct SJP to conventional treatment increased the curative efficacy and life quality of SA patients with no significant adverse drug reactions during the clinical application.

CLINICAL TRIAL REGISTRATION

(ID, ChiCTR1900021876, URL = http://www.chictr.org.cn/showproj.aspx?proj=34955).

Elucidation of the Molecular Mechanism of Compound Danshen Dripping Pills against Angina Pectoris based on Network Pharmacology and Molecular Docking

BACKGROUND

Compound Danshen dripping pills (CDDP), a traditional Chinese medicine, has had an extensive application in the treatment of angina pectoris (AP) in China. However, research on the bioactive ingredients and underlying mechanisms of CDDP in AP remains unclear.

OBJECTIVE

In the present study, we explored the major chemical components and potential molecular mechanisms linked to the anti-angina effects of CDDP through the application of network pharmacology and molecular docking.

METHODS

The potential targets of active ingredients in CDDP were sourced from the Traditional Chinese Medicine Systems Pharmacology Database (TCMSP) and the Swiss Target Prediction Database (STPD). Additionally, targets related to angina pectoris (AP) were retrieved from various databases, including Gene Cards, DisGeNET, Dis Genet, the Drug Bank database (DBD), and the Therapeutic Target Database (TDD). Protein- protein interaction networks were also established, and core targets were identified based on their topological significance. GO enrichment analysis and KEGG pathway analysis were conducted using the R software. Interactions between active ingredients and potential targets selected through the above process were investigated through molecular docking.

RESULTS

Seventy-six active ingredients were selected with the following criteria: OB ≥ 30%, DL ≥ 0.18. 383 targets of CDDP and 1488 targets on AP were gathered, respectively. Afterwards, 194 common targets of CDDP and anti-AP targets were defined, of which 12 were core targets. GO enrichment analysis indicated that CDDP acted on AP by response to lipopolysaccharide, regulating the reactive oxygen species and metal ion metabolism, and epithelial cell proliferation. In addition, KEGG enrichment analysis indicated that the signaling pathways were notably enriched in lipid and atherosclerosis, fluid shear stress and atherosclerosis, IL-17 signaling pathway, EGFR tyrosine kinase inhibitor resistance, PI3K-Akt signaling pathway, and TNF signaling pathway. Moreover, the molecular docking manifested excellent binding capacity between the active ingredients and targets on AP.

CONCLUSION

This study comprehensively illustrated the bioactive, potential targets, and molecular mechanisms of CDDP against AP, offering fresh perspectives into the molecular mechanisms of CDDP in preventing and treating AP.

Two-sample mendelian randomization analysis investigates ambient fine particulate matter's impact on cardiovascular disease development

PM2.5, a key component of air pollution, significantly threatens public health. Cardiovascular disease is increasingly associated with air pollution, necessitating more research. This study used a meticulous two-sample Mendelian randomization (MR) approach to investigate the potential causal link between elevated PM2.5 levels and 25 types of cardiovascular diseases. Data sourced from the UK Biobank, focusing on individuals of European ancestry, underwent primary analysis using Inverse Variance Weighting. Additional methods such as MR-Egger, weighted median, Simple mode, and Weighted mode provided support. Sensitivity analyses assessed instrument variable heterogeneity, pleiotropy, and potential weak instrument variables. The study revealed a causal link between PM2.5 exposure and higher diagnoses of Atherosclerotic heart disease (primary or secondary, OR [95% CI] 1.0307 [1.0103-1.0516], p-value = 0.003 and OR [95% CI] 1.0179 [1.0028-1.0333], p-value = 0.0202) and Angina pectoris (primary or secondary, OR [95% CI] 1.0303 [1.0160-1.0449], p-value = 3.04e-05 and OR [95% CI] 1.0339 [1.0081-1.0603], p-value = 0.0096). Additionally, PM2.5 exposure increased the likelihood of diagnoses like Other forms of chronic ischaemic heart disease (secondary, OR [95% CI] 1.0193 [1.0042-1.0346], p-value = 0.0121), Essential hypertension (secondary, OR [95% CI] 1.0567 [1.0142-1.1010], p-value = 0.0085), Palpitations (OR [95% CI] 1.0163 [1.0071-1.0257], p-value = 5e-04), and Stroke (OR [95% CI] 1.0208 [1.0020-1.0401], p-value = 0.0301). Rigorous sensitivity analyses confirmed these significant findings' robustness and validity. Our study revealed the causal effect between higher PM2.5 concentrations and increased cardiovascular disease risks. This evidence is vital for policymakers and healthcare providers, urging targeted interventions to reduce PM2.5 levels.

Tongxinluo capsule in combination with conventional therapies for stable angina pectoris: A meta-analysis and systematic review

BACKGROUND

This study aimed to assess the efficacy and safety of Tongxinluo capsule (TXLC) in combination with conventional therapies for treating stable angina pectoris (SAP) through a comprehensive meta-analysis and systematic review.

METHODS

We conducted a systematic search of the China National Knowledge Infrastructure, Wanfang, VIP, PubMed, Embase, and CENTRAL databases for randomized controlled trials investigating the use of TXLC as adjuvant therapy for SAP published up to June 2023. The Cochrane Handbook was used to evaluate the risk of bias. Meta-analysis was performed using Review Manager 5.4.1, and publication bias was assessed using Begg test and Egger test in the Stata SE 12.0 software. GRADEpro was used to assess the quality of the evidence.

RESULTS

This meta-analysis included 26 randomized controlled trials with a total of 2352 patients. TXLC co-administration demonstrated significant reduction in angina attack frequency (mean difference (MD) -0.91, 95% confidence interval (CI) -0.97 to -0.84, P < .00001) and duration (MD -1.71, 95% CI -2.24 to -1.19, P < .00001), decreased use of nitroglycerin tablets (MD -6.28, 95% CI -7.16 to -5.41, P < .00001), lowered C-reactive protein (MD -1.19, 95% CI -1.35 to -1.03, P < .00001) and low-density lipoprotein cholesterol levels (MD -0.68, 95% CI -0.86 to -0.51, P < .00001). TXLC co-administration did not increase gastrointestinal reactions (RR 1.17, 95% CI 0.38 to 3.57, P = .78). The Begg test and Egger test results indicated no publication bias. The evidence quality was rated as very low for frequency of angina attack, duration of angina attack, and nitroglycerin usage, and low for C-reactive protein, low-density lipoprotein cholesterol levels, and gastrointestinal reaction events.

CONCLUSION

This meta-analysis supports TXLC as a beneficial adjunct treatment for SAP.

Myocardial revascularization failure among patients requiring cardiac catheterization and secondary revascularization in contemporary clinical practice: Results of the REVASEC multicenter registry

BACKGROUND

Myocardial revascularization failure (MRF) and Secondary revascularization (SR) are contemporary interventional cardiology challenges.

AIM

To investigate the characteristics, management, and prognosis of patients with myocardial revascularization failure (MRF) and need for secondary revascularization (SR) in contemporary practice.

METHODS

The REVASEC study is a prospective registry (NCT03349385), which recruited patients with prior revascularization referred for coronary angiography at 19 centers. The primary endpoint is a patient-oriented composite (POCE) at 1 year, including death, myocardial infarction, or repeat revascularization.

RESULTS

A total of 869 patients previously revascularized by percutaneous intervention (83%) or surgery (17%) were recruited. MRF was found in 83.7% (41.1% stent/graft failure, 32.1% progression of coronary disease, and 10.5% residual disease). SR was performed in 70.1%, preferably by percutaneous intervention (95%). The POCE rate at 1 year was 14% in the overall cohort, with 6.4% all-cause death. In the multivariate analysis, lower POCE rates were found in the groups without MRF (9.4%) and with disease progression (11%) compared with graft/stent failure (17%) and residual disease (18%), hazard ratio 0.67 (95% confidence interval: 0.45-0.99), p = 0.043. At 1 year, the SR group had less chronic persistent angina (19% vs. 34%, p < 0.001), but a higher rate of repeat revascularization (9% vs. 2.9%, p < 0.001).

CONCLUSION

MRF was found in 84% of patients with prior revascularization referred for coronary angiography. Stent/graft failure and residual coronary disease were associated with a worse prognosis. SR provided better symptom control at the expense of a higher rate of new revascularization.

Effectiveness of Shuxuening injection in coronary heart disease: a systematic review and meta-analysis

Background: Coronary heart disease (CHD) poses a serious threat to public health, and the current medical management still faces significant challenges. Reliable evidence on the efficacy of Shuxuening injection (SXNI) in CHD is still lacking, even though it is widely used in China. Purpose: To evaluate the efficacy of SXNI combination therapy in treating CHD. Methods: A systematic search of eight databases was conducted to identify relevant randomized controlled trials (RCTs) from the inception of each database until June 2023. ROB 2.0, RevMan 5.4, and Stata 15.1 were used for quality evaluation and data analysis. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Results: A total of 3,779 participants from 39 studies were included. The results showed SXNI combination therapy increased the clinical efficacy and decreased the frequency and duration of angina. Furthermore, SXNI combination therapy improved cardiac function of patients by decreasing LVEDD, and increased CI, CO, and LVEF. It also improved blood lipid profiles by increasing HDL, decreasing TC, TG, and LDL. The thrombosis factors of patients were also improved by decreasing FIB, PV, HCT, and HS. Moreover, SXNI combination therapy was superior to the conventional treatment in improving CRP levels, increasing ECG efficacy and BNP. However, due to the limited safety information, reliable safety conclusions could not be drawn. Furthermore, the levels of evidence ranged from very low to moderate due to publication bias and heterogeneity. Conclusion: SXNI can effectively improve angina symptoms, clinical efficacy, cardiac function, blood lipid indicators, and thrombosis factors of patients with CHD. However, more multi-center and large-sample studies are needed to confirm the conclusions due to the limitations of this study. Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=399606; Identifier: CRD42023433292.

Vasospastic angina: Past, present, and future

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.

Myocardial injury before noncardiac surgery

Non-cardiac surgical procedures present a significant circulatory stress and can potentially trigger cardiovascular events, such as myocardial infarction and heart failure. Myocardial injury before non-cardiac surgery is associated with an increased risk of mortality and major cardiovascular complications during perioperative period, as well as up to 5 years after non-cardiac surgery. While the definition of preoperative myocardial injury is not yet clear, it is generally understood as myocardial injury resulting from various causes of troponin elevation without acute coronary syndrome prior to surgery. Detecting preoperative myocardial injury through routine troponin monitoring is crucial for reducing perioperative risk, but it is also challenging. The aim of this review is to discuss the definition of preoperative myocardial injury, its pathophysiology, implications on clinical practice and decision-making for patients with elevated troponin levels before non-cardiac surgery.

Diagnostic Strategies for the Assessment of Suspected Stable Coronary Artery Disease : A Systematic Review and Meta-analysis

BACKGROUND

There is uncertainty about which diagnostic strategy for detecting coronary artery disease (CAD) provides better outcomes.

PURPOSE

To compare the effect on clinical management and subsequent health effects of alternative diagnostic strategies for the initial assessment of suspected stable CAD.

DATA SOURCES

PubMed, Embase, and Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Randomized clinical trials comparing diagnostic strategies for CAD detection among patients with symptoms suggestive of stable CAD.

DATA EXTRACTION

Three investigators independently extracted study data.

DATA SYNTHESIS

The strongest available evidence was for 3 of the 6 comparisons: coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) (4 trials), CCTA versus exercise electrocardiography (ECG) (2 trials), and CCTA versus stress single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) (5 trials). Compared with direct ICA referral, CCTA was associated with no difference in cardiovascular death and myocardial infarction (relative risk [RR], 0.84 [95% CI, 0.52 to 1.35]; low certainty) but less index ICA (RR, 0.23 [CI, 0.22 to 0.25]; high certainty) and index revascularization (RR, 0.71 [CI, 0.63 to 0.80]; moderate certainty). Moreover, CCTA was associated with a reduction in cardiovascular death and myocardial infarction compared with exercise ECG (RR, 0.66 [CI, 0.44 to 0.99]; moderate certainty) and SPECT-MPI (RR, 0.64 [CI, 0.45 to 0.90]; high certainty). However, CCTA was associated with more index revascularization (RR, 1.78 [CI, 1.33 to 2.38]; moderate certainty) but less downstream testing (RR, 0.56 [CI, 0.45 to 0.71]; very low certainty) than exercise ECG. Low-certainty evidence compared SPECT-MPI versus exercise ECG (2 trials), SPECT-MPI versus stress cardiovascular magnetic resonance imaging (1 trial), and stress echocardiography versus exercise ECG (1 trial).

LIMITATION

Most comparisons primarily rely on a single study, many studies were underpowered to detect potential differences in direct health outcomes, and individual patient data were lacking.

CONCLUSION

For the initial assessment of patients with suspected stable CAD, CCTA was associated with similar health effects to direct ICA referral, and with a health benefit compared with exercise ECG and SPECT-MPI. Further research is needed to better assess the relative performance of each diagnostic strategy.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42022329635).

Reporting quality of randomized controlled trials of angina pectoris with integrated traditional Chinese and western medicine interventions: a cross-sectional study

BACKGROUND AND OBJECTIVE

Integrated traditional Chinese and western medicine (ITCWM), as a representative type of complex intervention, is commonly used for the treatment of angina pectoris (AP) in clinical practice. However, it is unclear whether the details of ITCWM interventions, such as rationale for selection and design, implementation and potential interactions for different therapies, were adequately reported. Therefore, this study aimed to describe the reporting characteristics and quality in randomized controlled trials (RCTs) of AP with ITCWM interventions.

METHODS

Through a search of 7 electronic databases, we identified RCTs of AP with ITCWM interventions published in both English and Chinese from 1^st Jan 2017 to 6^th Aug 2022. The general characteristics of included studies were summarized, further, the quality of reporting was assessed based on three Checklists, including the CONSORT with 36 items (except for one item 1b about abstract), the CONSORT for abstracts (17 items), and a self-designed ITCWM-related checklist (21 items covering rationale and details of interventions, outcome assessment and analysis). The quality of RCTs published in English and Chinese, as well as journals and dissertations were also compared.

RESULTS

A total of 451 eligible RCTs were included. For the reporting compliance, the mean score (95% Confidence Interval) of the CONSORT (72 scores in total), CONSORT for abstract (34 scores in total), and ITCWM-related (42 scores in total) checklists was 27.82 (27.44-28.19), 14.17 (13.98-14.37) and 21.06 (20.69-21.43), respectively. More than half items were evaluated as poor quality (reporting rate < 50%) among each Checklist. Moreover, the reporting quality of publications in English journals was higher than that in Chinese journals in terms of the CONSORT items. The reporting of published dissertations was better than that in journal publications regarding both the CONSORT and ITCWM-specific items.

CONCLUSION

Although the CONSORT appears to have enhanced the reporting of RCTs in AP, the quality of ITCWM specifics is variable and in need of improvement. Reporting guideline of the ITCWM recommendations should be developed thus to improve their quality.

Compound danshen dripping pills vs. nitrates for stable angina pectoris: a systematic review and meta-analysis

Background

Long-term use of nitrates for treating stable angina pectoris (SAP) may lead to patients' tolerance to nitrates. As a traditional Chinese medicine, Compound danshen dropping pills (CDDP) is beneficial for patients with SAP. This study aimed to critically assess the efficacy and safety of CDDP vs. nitrates for SAP.

Methods

PubMed, Embase, Web of Science, Cochrane library, CNKI, Wanfang Digital Periodicals, and Chinese Science and Technology Periodicals database were searched from inception to April 2023. Randomized controlled trials (RCTs) comparing CDDP with nitrates for SAP were included. The meta-analysis was conducted to estimate the pooled effect.

Results

Twenty-nine studies were included for the statistical analysis. The meta-analyses with the random-effect model indicated that CDDP could significantly increase the effective rate in symptom improvement compared with nitrates (Pooled 9 RCTs, OR = 1.95, 95% CI: 1.25-3.05, P = 0.003, duration of 4 weeks; Pooled 4 RCTs, OR = 3.45, 95% CI: 1.84-6.48, P = 0.0001, duration of 6 weeks; Pooled 13 RCTs, OR = 4.02, 95% CI: 2.14-7.57, P < 0.0001, duration of 8 weeks). The meta-analyses with the random-effect model indicated that CDDP could significantly increase the effective rate in electrocardiogram improvement compared with nitrates (Pooled 5 RCTs, OR = 1.60, 95% CI: 1.02-2.52, P = 0.04, duration of 4 weeks; Pooled 3 RCTs, OR = 2.47, 95% CI: 1.60-3.82, P < 0.0001, duration of 6 weeks; Pooled 11 RCTs, OR = 3.43, 95% CI: 2.68-4.38, P < 0.00001, duration of 8 weeks). The incidence of adverse drug reactions in the CDDP group was lower than that in the nitrates group (Pooled 23 RCTs, OR = 0.15, 95% CI: 0.1-0.21, P < 0.00001). The results of the meta-analyses with fixed-effect model were similar with above results. The levels of the evidence ranged from very low to low.

Conclusion

The present study suggests that CDDP with the duration of at least 4 weeks can be considered as an alternative to nitrates for treating SAP. However, more high-quality RCTs are still needed to confirm these findings.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022352888, identifier [CRD42022352888].

Integrated Chinese and Western medicine for stable angina pectoris of coronary heart disease: a real-world study including 690 patients

Objective

We aimed to evaluate the effects of integrated Chinese and Western medical therapeutic modalities on clinical prognosis in a population with stable angina pectoris (SAP) of coronary heart disease (CHD).

Methods

In a prospective cohort study, 732 patients with SAP of CHD hospitalized in the Integrated Cardiology Unit of the China-Japan Friendship Hospital From October 2020 to October 2021 were included. The patients were divided into integrated treatment and conventional treatment groups according to whether they had been taking Chinese medicine for more than 6 months per year. The occurrence of composite cardiovascular events (CVEs), including cardiac death, non-fatal myocardial infarction, revascularization, stroke, all-cause death, and readmission due to angina attack, heart failure, or malignant arrhythmia, was recorded during follow-up. The effects of different treatment modalities on prognosis were evaluated using univariate and multifactorial logistic regression. Logistic regression models were evaluated using receiver operating characteristic (ROC) curves. In sensitivity analysis, the correlation between treatment modality and outcome events was corrected by rematching the two groups of patients using the propensity score matching (PSM) method.

Results

The data from 690 patients were included in the analysis, with 327 patients in the integrated treatment group and 363 patients in the conventional treatment group. CVEs occurred in 19 patients (5.8%) in the integrated treatment group and 37 patients (10.2%) in the conventional treatment group. The proportion of outcome events was significantly lower in the combination treatment group than in the conventional treatment group (P = 0.037). Covariate correction by multimodal multifactorial logistic regression revealed a lower risk of CVEs in patients receiving integrated therapy compared with conventional therapy (OR = 0.246, 95% CI = 0.097-0.622, P = 0.003). Moreover, a history of renal insufficiency (OR = 3.991, 95% CI = 1.164-13.684, P = 0.028) and a higher Gensini score (OR = 1.039, 95% CI = 1.028-1.050, P < 0.001) were risk factors for the development of CVEs. Model evaluation showed that C-statistic = 0.955 and area under the ROC curve (AUC) = 0.955. After PSM correction, the results still showed that integrated Chinese and Western medical treatment reduced the occurrence of CVEs in patients compared with Western treatment alone (OR = 0.339, 95% CI = 0.131-0.874, P = 0.025).

Conclusion

Integrated treatment based on Chinese and Western medicine might improve the prognosis and reduce the risk of CVEs in this disease population.

Trial registration

China Clinical Trials Registry, ChiCTR1800017891, Registered 20 August 2018, http://www.chictr.org.cn/showproj.aspx?proj = 30170.

Development of a risk score model for the prediction of patients needing percutaneous coronary intervention

BACKGROUND

The incidence of coronary heart disease (CHD) is increasing worldwide. The need for percutaneous coronary intervention (PCI) is determined by coronary angiography (CAG). As coronary angiography is an invasive and risky test for patients, it will be of great help to develop a predicting model for the assessment of the probability of PCI in patients with CHD using the test indexes and clinical characteristics.

METHODS

A total of 454 patients with CHD were admitted to the cardiovascular medicine department of a hospital from January 2016 to December 2021, including 286 patients who underwent CAG and were treated with PCI, and 168 patients who only underwent CAG to confirm the diagnosis of CHD were set as the control group. Clinical data and laboratory indexes were collected. According to the clinical symptoms and the examination signs, the patients in the PCI therapy group were further split into three subgroups: chronic coronary syndrome (CCS), unstable angina pectoris (UAP), and acute myocardial infarction (AMI). The significant indicators were extracted by comparing the differences among the groups. A nomogram was drawn based on the logistic regression model, and predicted probabilities were performed using R software (version 4.1.3).

RESULTS

Twelve risk factors were selected by regression analysis; the nomogram was successfully constructed to predict the probability of needing PCI in patients with CHD. The calibration curve shows that the predicted probability is in good agreement with the actual probability (C-index = 0.84, 95% CI = 0.79-0.89). According to the results of the fitted model, the ROC curve was plotted, and the area under the curve was 0.801. Among the three subgroups of the treatment group, 17 indexes were statistically different, and the results of the univariable and multivariable logistic regression analysis revealed that cTnI and ALB were the two most important independent impact factors.

CONCLUSION

cTnI and ALB are independent factors for the classification of CHD. A nomogram with 12 risk factors can be used to predict the probability of requiring PCI in patients with suspected CHD, which provided a favorable and discriminative model for clinical diagnosis and treatment.

Cervical Angina as a Cause of Non-Cardiac Chest Pain: A Case Report

Cervical angina is a form of non-cardiac chest pain that originates in the cervical spine or cervical cord; it is an under-recognized and easily underdiagnosed condition. Patients with cervical angina often report delayed diagnosis. Here, we report the case of a 62-year-old woman with a history of cervical spondylosis and undiagnosed recurrent chest pain who presented with numbness in the left upper arm and was diagnosed with cervical angina. Although most cases of cervical angina involve uncommon self-limited diseases that improve with conservative treatment, timely diagnosis can reduce patient anxiety and unnecessary office visits and tests. The critical aspect of chest pain evaluation is to rule out fatal disease. Once fatal disease is ruled out, cervical angina should be considered in differential diagnosis if there is a history of cervical spine disease, if the pain radiates to the arm, if it is elicited by cervical spine range of motion or upper extremity movement, or if the chest pain lasts less than a few seconds.

Prediction of Angina Pectoris Events in Middle-Aged and Elderly People Using RR Interval Time Series in the Resting State: A Cohort Study Based on SHHS

Angina pectoris is associated with adverse cardiovascular events. In this study, a Bi-directional Long Short-Term Memory (Bi-LSTM) prediction model with the Attention layer was established to explore the predictive value of the resting-state RR interval time series on the occurrence of angina pectoris. The data of this cohort study were from the Sleep Heart Health Study database, 2,977 people were included with the follow-up of 15 years. We used the RR interval time series of electrocardiogram signals in the resting state. The outcome variables were any angina events during the follow-up. We randomly divided 2,977 participants into training (n = 2680) and testing sets (n = 297) with a partition ratio of 9:1. The prediction model of Bi-LSTM with Attention layer was developed and the predictive performance was assessed. 1,236 had angina pectoris and 1,741 patients did not have angina pectoris during the follow-up period. The predictive performance of the Bi-LSTM model was great with the value of accuracy = 0.913, area under the curve (AUC) = 0.922, precision = 0.913 in the testing set. RR intervals may be the potential predictors of angina events. It is more and more convenient to obtain heart rate with the development of wearable devices; the Bi-LSTM prediction model established in this study is expected to provide support for the intelligent prediction of angina pectoris events.

Adherence to the Mediterranean Diet Association with Serum Levels of Nitric Oxide, Prostacyclin, and Thromboxane B2 among Prinzmetal Angina Patients and Healthy Persons

This study aimed to assess the association between adherence to the Mediterranean diet with serum Nitric oxide, Prostacyclin, and Thromboxane B₂ among Prinzmetal angina patients and healthy persons. This case-control study was conducted among 100 Prinzmetal angina patients and 100 healthy persons referred to the Ardabil Imam Khomeini hospital between 2021 and 2022. Blood samples were obtained from all study participants for measurement of serum Nitric oxide, Prostacyclin, and Thromboxane B₂. To calculate adherence to the Mediterranean diet, the ten-item screener was used. The serum Nitric oxide in patients who adhered more to the Mediterranean diet was higher than patients with less adherence (coeff. = 0.41 p = 0.04). The serum Prostacyclin level in patients with greater adherence to the Mediterranean diet was 0.34 units higher than patients with less adherence (coeff. = 0.34 p = 0.02). The level of serum Thromboxane B₂ had a negative association with adherence to the Mediterranean diet (coeff. = -0.48 p = 0.04). The amount of consumption of olive oil, fruits, vegetables, and legumes in healthy people was more than Prinzmetal angina patients. In Prinzmetal angina patients, more adherence to the Mediterranean diet can decrease the serum Thromboxane B₂ and increase the serum Nitric oxide and Prostacyclin.

Distinguish the Characteristic Mechanism of 3 Drug Pairs of Corydalis Rhizome in Ameliorating Angina Pectoris: Network Pharmacology and Meta-Analysis

Objective: Angina pectoris (AP), affecting over 523 million people, can be alleviated by corydalis rhizome (CR), usually combined with chuanxiong rhizome (CXR), angelica dahuricae radix (ADR), or astragali radix (AR) to enhance the effect. This study aims to distinguish the different mechanisms among 3 drug pairs to treat AP. Methods: The drug pair-disease intersection targets, compound targets, protein–protein interaction (PPI), and herb-compound-target-pathway network were obtained by Cytoscape, STRING, Gene Ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses ( http://www.kegg.jp/ or http://www.genome.jp/kegg/ ). Importantly, with principal component analysis (PCA), the key point of KEGG and GO were explored and supported, while by meta-analysis, the different mechanisms of the drug pairs on AP were discovered. Results: JUN, SRC, PIK3CA, and MAPK1 as PPI core network of CR-AP, (CR-CXR)-AP, (CR-ADR)-AP, and (CR-AR)-AP. (highest confidence > 0.9). 10, 45, 35, and 21 key compounds, and 68, 123, 117, and 97 core targets were obtained from CR-AP, (CR-CXR)-AP, (CR-ADR)-AP, and (CR-AR)-AP based on more than 2-fold median value for degree and betweenness centrality, more than the median of closeness centrality. The core pathways of (CR-CXR)-AP and (CR-AR)-AP cover “fluid shear stress and atherosclerosis” and the “pathways in cancer”, while (CR-ADR)-AP was found as the “pathways in cancer” by PCA and KEGG ( P < .01). The core biological processes of (BP) (CR-CXR)-AP, (CR-ADR)-AP, and (CR-AR)-AP were all enriched in the “circulatory system process” by PCA and GO ( P < .01). Moreover, meta-analysis indicated the significant differences ( P < .05) of the 3 drug pairs. Conclusion: CR-CXR, CR-ADR, or CR-AR outperformed CR-AP in AP mitigation. Furthermore, meta-analysis revealed, CR-CXR was superior to alleviating AP by affecting “circulatory system process” and “fluid shear stress and atherosclerosis”, particularly the targets PTGS1, PTGS2, ADRB2, ADRA2C, and NOS, when compared with the drug pair of CR-ADR and the CR-AR.

Assessment of the Efficiency of Non-Invasive Diagnostic Imaging Modalities for Detecting Myocardial Ischemia in Patients Suspected of Having Stable Angina

This study aimed to assess and compare the efficiency of non-invasive imaging modalities in detecting myocardial ischemia in patients with suspected stable angina as easy-to-understand indices. Our study included 1000 patients with chest pain and possible stable myocardial ischemia. The modalities to be assessed were cardiac magnetic resonance imaging (CMRI), single-photon emission computed tomography, positron emission computed tomography (PET), stress echocardiography, and fractional flow reserve derived from coronary computed tomography angiography (FFRCT). As a simulation study, we assumed that all five imaging modalities were performed on these patients, and a decision tree analysis was conducted. From the results, the following efficiencies were assessed and compared: (1) number of true positive (TP), false positive (FP), false negative (FN), and true negative (TN) test results; (2) positive predictive value (PPV); (3) negative predictive value (NPV); (4) post-test probability; (5) diagnostic accuracy (DA); and (6) number needed to diagnose (NND). In the basic settings (pre-test probability: 30%), PET generated the highest TP (267) and NPV (95%, 95% confidence interval (CI): 93-96%). In contrast, CMRI produced the highest TN (616), PPV (76%, 95% CI: 71-80%), and DA (88%, 95% CI: 86-90%) and the lowest NND (1.33, 95% CI: 1.24-1.47). Although FFRCT generated the highest TP (267) and lowest FN (33), it generated the highest FP (168). In terms of detecting myocardial ischemia, compared with the other modalities, PET and CMRI were more efficient. The results of our study might be helpful for both patients and medical professionals associated with their examination.

Non-acute chest pain in primary care; referral rates, communication and guideline adherence: a cohort study using routinely collected health data

BACKGROUND

The prevalence of coronary artery disease is increasing due to the aging population and increasing prevalence of cardiovascular risk factors. Non-acute chest pain often is the first symptom of stable coronary artery disease. To optimise care for patients with non-acute chest pain and make efficient use of available resources, we need to know more about the current incidence, referral rate and management of these patients.

METHODS

We used routinely collected health data from the STIZON data warehouse in the Netherlands between 2010 and 2016. Patients > 18 years, with no history of cardiovascular disease, seen by the general practitioner (GP) for non-acute chest pain with a suspected cardiac origin were included. Outcomes were (i) incidence of new non-acute chest pain in primary care, (ii) referral rates to the cardiologist, (iii) correspondence from the cardiologist to the GP, (iv) registration by GPs of received correspondence and; (v) pharmacological guideline adherence after newly diagnosed stable angina pectoris.

RESULTS

In total 9029 patients were included during the study period, resulting in an incidence of new non-acute chest pain of 1.01/1000 patient-years. 2166 (24%) patients were referred to the cardiologist. In 857/2114 (41%) referred patients, correspondence from the cardiologist was not available in the GP's electronic medical record. In 753/1257 (60%) patients with available correspondence, the GP did not code the conclusion in the electronic medical record. Despite guideline recommendations, 37/255 (15%) patients with angina pectoris were not prescribed antiplatelet therapy nor anticoagulation, 69/255 (27%) no statin and 67/255 (26%) no beta-blocker.

CONCLUSION

After referral, both communication from cardiologists and registration of the final diagnosis by GPs were suboptimal. Both cardiologists and GPs should make adequate communication and registration a priority, as it improves health outcomes. Secondary pharmacological prevention in patients with angina pectoris was below guideline standards. So, proactive attention needs to be given to optimise secondary prevention in this high-risk group in primary care.

CHA2DS2-VASc score for in-hospital recurrence risk stratification in patients with myocardial infarction

BACKGROUND

Using the CHA2DS2-VASc score to recognize the risk of stroke in patients with atrial fibrillation has been well-established. However, few studies have assessed whether the CHA2DS2-VASc score has a similar predictive value in recurrence after myocardial infarction (MI).

METHODS

We conducted a retrospective observational cohort study of adult inpatients with MI. The CHA2DS2-VASc and modified CHA2DS2-VASc (MCHA2DS2-VASc) scores of all patients were calculated. The associations of both scores with recurrent MI were analyzed.

RESULTS

A total of 6,700 patients with MI (60.0 ± 11.1 years, 77.2% men) were enrolled, and 759 (11.3%) presented a definite recurrence during hospitalization. After multivariable adjustment by logistic regression in patients with MI, the CHA2DS2-VASc and MCHA2DS2-VASc scores were independently associated with recurrence. The MCHA2DS2-VASc score showed a better predictive value for risk of recurrence than that of CHA2DS2-VASc in overall [area under the receiver operating characteristic curve (AUC) 0.757 vs. 0.676] or male patients (AUC 0.759 vs. 0.708). MCHA2DS2-VASc was superior to CHA2DS2-VASc for identifying "truly high-risk" patients with MI, regardless of overall patients or sex-specific subgroups. The two scores had a similar focus on the identification of "low-risk" patients in overall or women, but not in men.

CONCLUSION

The CHA2DS2-VASc and MCHA2DS2-VASc scores for predicting recurrence are validated in patients with MI. However, MCHA2DS2-VASc could be more helpful to secondary prevention than CHA2DS2-VASc after MI, especially in men. The superiority of MCHA2DS2-VASc compared with CHA2DS2-VASc in women is just more discriminatory for "truly high-risk" patients.

Angina in 2022: Current Perspectives

Angina is the main symptom of ischemic heart disease; mirroring a mismatch between oxygen supply and demand. Epicardial coronary stenoses are only responsible for nearly half of the patients presenting with angina; whereas in several cases; symptoms may underlie coronary vasomotor disorders; such as microvascular dysfunction or epicardial spasm. Various medications have been proven to improve the prognosis and quality of life; representing the treatment of choice in stable angina and leaving revascularization only in particular coronary anatomies or poorly controlled symptoms despite optimal medical therapy. Antianginal medications aim to reduce the oxygen supply-demand mismatch and are generally effective in improving symptoms; quality of life; effort tolerance and time to ischemia onset and may improve prognosis in selected populations. Since antianginal medications have different mechanisms of action and side effects; their use should be tailored according to patient history and potential drug-drug interactions. Angina with non-obstructed coronary arteries patients should be phenotyped with invasive assessment and treated accordingly. Patients with refractory angina represent a higher-risk population in which some therapeutic options are available to reduce symptoms and improve quality of life; but robust data from large randomized controlled trials are still lacking.

Exploring the therapeutic mechanism of Baduanjin in the treatment of elderly stable angina pectoris based on the gut microbiota-lipid metabolism spectrum: Study protocol for a randomized controlled trial

Importance

Stable angina pectoris (SAP) often occurs in the elderly and is relatively stable for 1-3 months; however, if patients do not receive effective treatment, life-threatening acute myocardial infarction could occur. Patients with different clinical types of coronary heart disease have different intestinal flora. Baduanjin, a traditional Chinese Qigong, has been used as adjuvant therapy to improve the symptoms of patients with SAP.

Objective

To determine the effect of Baduanjin exercise on the symptoms of patients with SAP and the intestinal flora, explore the action links and targets of Baduanjin intervention in elderly patients with SAP, and explain its mechanism.

Design

A single-center, single-blind, randomized controlled trial. Patients and outcome assessors were blinded to group allocation.

Setting

The trial will be conducted at Guang'anmen Hospital of China Academy of Chinese Medical Sciences.

Participants

One hundred and eighty patients aged 60 to 80 years with stable angina pectoris (I-III) were intervened for 8 weeks and followed up for half a year.

Interventions

Among the screened patients, 180 patients will be randomly assigned to either the Baduanjin or the control group at a 1:1 ratio (exercise duration: for 3-5 times a week, for 8 weeks) of moderate-intensity Baduanjin or free activities.

Main and secondary results

The main result is the total effective rate for angina pectoris symptoms; secondary results include the duration of angina pectoris, number of angina pectoris episodes per week, nitroglycerin consumption, nitroglycerin reduction rate, Seattle angina score (SAQ), quality of life (SF-36),Traditional Chinese Medicine (TCM) syndrome scores, electrocardiogram (ECG) changes, blood lipid serum hypersensitive C-reactive protein levels, intestinal flora changes, serum changes in the intestinal flora metabolite Trimetlylamine oxide (TMAO), and non-targeted liposome detection. Adverse events will be recorded throughout the experiment, and the data will be analyzed by researchers who did not know about the assignment.

Discussion

This study provides compelling evidence for at-home use of Baduanjin exercise to relieve SAP-associated symptoms.

Trial registration

This study was approved by the ethics committee of Guang'anmen Hospital of China Academy of Chinese Medical Sciences (2022-121-KY). The trial has been registered in Chinese Clinical Trial Registration Center (ChiCTR2200062450).

Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial

OBJECTIVE

To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease.

DESIGN

Prospective, multicentre, randomised pragmatic trial.

SETTING

Hospitals at 26 sites in 16 European countries.

PARTICIPANTS

2002 (56.2%) women and 1559 (43.8%) men (total of 3561 patients) with suspected coronary artery disease referred for invasive coronary angiography on the basis of stable chest pain and a pre-test probability of obstructive coronary artery disease of 10-60%.

INTERVENTION

Both women and men were randomised 1:1 (with stratification by gender and centre) to a strategy of either computed tomography or invasive coronary angiography as the initial diagnostic test (1019 and 983 women, and 789 and 770 men, respectively), and an intention-to-treat analysis was performed. Randomised allocation could not be blinded, but outcomes were assessed by investigators blinded to randomisation group.

MAIN OUTCOME MEASURES

The primary endpoint was major adverse cardiovascular events (MACE; cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Key secondary endpoints were an expanded MACE composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, transient ischaemic attack, or major procedure related complication) and major procedure related complications.

RESULTS

Follow-up at a median of 3.5 years was available in 98.9% (1979/2002) of women and in 99.0% (1544/1559) of men. No statistically significant gender interaction was found for MACE (P=0.29), the expanded MACE composite (P=0.45), or major procedure related complications (P=0.11). In both genders, the rate of MACE did not differ between the computed tomography and invasive coronary angiography groups. In men, the expanded MACE composite endpoint occurred less frequently in the computed tomography group than in the invasive coronary angiography group (22 (2.8%) v 41 (5.3%); hazard ratio 0.52, 95% confidence interval 0.31 to 0.87). In women, the risk of having a major procedure related complication was lower in the computed tomography group than in the invasive coronary angiography group (3 (0.3%) v 21 (2.1%); hazard ratio 0.14, 0.04 to 0.46).

CONCLUSION

This study found no evidence for a difference between women and men in the benefit of using computed tomography rather than invasive coronary angiography as the initial diagnostic test for the management of stable chest pain in patients with an intermediate pre-test probability of coronary artery disease. An initial computed tomography scan was associated with fewer major procedure related complications in women and a lower frequency of the expanded MACE composite in men.

TRIAL REGISTRATION

NCT02400229ClinicalTrials.gov NCT02400229.

The comparative effects of oral Chinese patent medicines combined with western medicine in stable angina: A systematic review and network meta-analysis of 179 trials

Background: Stable angina is a common condition with high morbidity and mortality rates. It has been reported that combining oral Chinese patent medicines (OCPMs) and Western medicine (WM) could potentially achieve a better effect than WM alone. However, the optimal OCPMs for stable angina remain controversial and merit further empirical research.

Methods: PubMed, Embase, Web of Science, Cochrane Library, Ovid-Medline, Clinical Trials.gov, China National Knowledge Infrastructure, Wanfang Database, Weipu Journal Database, and Chinese Biomedical Literature Database were all searched from inception to 13 March 2022. We employed Version 2 of the Cochrane risk-of-bias tool (ROB2) to assess the overall quality of the selected studies. We also used R 4.1.2 and STATA 14.0 software applications to perform network meta-analysis, followed by sensitivity and subgroup analysis.

Results: A total of 179 randomized controlled trials with 16,789 patients were included. The selected trials were all assessed as some concerns. OCPMs combined with WM had a better treatment effect than WM alone. In terms of the effective clinical rate, a significant increase was detected for Qishen Yiqi dripping pill (QSYQ)+WM as compared with Shensong Yangxin capsule (SSYX)+WM, Shexiang Baoxin pill (SXBX)+WM, Tongxinluo capsule (TXL)+WM, Xuefu Zhuyu capsule (XFZY)+WM, Qiliqiangxin capsule (QLQX)+WM, Naoxintong capsule (NXT)+WM, Fufang Danshen dripping pill (FFDS)+WM, and Danlou tablet (DL)+WM. QSYQ + WM had the highest-ranking probability (98.12%). Regarding the effective rate in ECG, QSYQ + WM was superior to SXBX + WM, TXL + WM, DL + WM, FFDS + WM, and NXT + WM. QSYQ + WM ranked first (94.21%). In terms of weekly frequency of angina, QLQX + WM obtained a better effect than FFDS + WM, Kuanxiong aerosol (KXQW)+WM, NXT + WM, QLQX + WM, SSYX + WM, SXBX + WM, and TXL + WM. QLQX + WM ranked first (100.00%). Regarding the duration of an angina attack, KXQW + WM was superior to SSYX + WM; KXQW + WM ranked first (95.71%). Adverting to weekly nitroglycerin usage, TXL + WM had the highest-ranking probability (82.12%). Referring to cardiovascular event rate, DL + WM had the highest effect (73.94%). Additionally, SSYX + WM had the lowest rate of adverse drug reactions (1.14%).

Conclusion: OCPMs combined with WM had a higher efficacy. QSYQ + WM, QLQX + WM, KXQW + WM, TXL + WM, DL + WM, SSYX + WM, and SXBX + WM merit further investigation. SXBX + WM is presumably the optimal treatment prescription for both clinically effective and cardiovascular event rates. Further high-quality empirical research is needed to confirm the current results.

Systematic Review Registration: URL = https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=316534, CRD 42022316534

New Therapeutic Options for Type 2 Diabetes Mellitus and Their Impact Against Ischemic Heart Disease

Type 2 diabetes mellitus (T2DM) greatly increases risk for cardiovascular disease, including ischemic heart disease and myocardial infarction. With the completion of several cardiovascular outcomes trials (CVOTs) for new glucose-lowering therapies, including the sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor (GLP-1R) agonists, we now have strong evidence alluding to the cardioprotective nature of these agents in people with T2DM. These agents have frequently been observed to reduce rates for 3-point major adverse cardiovascular events, which encompass death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. Herein we will provide an overview on whether reductions in nonfatal myocardial infarction and ischemic heart disease status are a key component of the improved cardiovascular outcomes in people with T2DM treated with either SGLT2 inhibitors or GLP-1R agonists. Observations from preclinical studies will be compared to their clinical counterparts, while being further interrogated to define potential mechanisms that may account for SGLT2 inhibitor or GLP-1R agonist-induced cardioprotection against ischemic heart disease. A better understanding of the role these agents have in impacting the progression of ischemic heart disease in individuals with T2DM will have a substantial impact in our management of this patient population.

Revascularization in stable coronary artery disease

Management of stable coronary artery disease (CAD) centers on medication to prevent myocardial infarction and death. Many anti-anginal medications also have benefit for reducing symptoms, and have been proven to be effective against placebo control. Before effective preventive medications were available, patients with stable CAD often underwent revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), on the plausible assumption that these procedures would prevent adverse events and reduce symptoms. However, recent randomized controlled trials have cast doubt on these assumptions.Considering results from the recent ISCHEMIA trial, we discuss the evidence base that underpins revascularization for stable CAD in contemporary practice. We also focus on patient groups at high risk of myocardial infarction and death, for whom revascularization is often recommended. We outline the areas of uncertainty, unanswered research questions, and key areas of potential miscommunication in doctor-patient consultations.

Using Text Content From Coronary Catheterization Reports to Predict 5-Year Mortality Among Patients Undergoing Coronary Angiography: A Deep Learning Approach

Background

Current predictive models for patients undergoing coronary angiography have complex parameters which limit their clinical application. Coronary catheterization reports that describe coronary lesions and the corresponding interventions provide information of the severity of the coronary artery disease and the completeness of the revascularization. This information is relevant for predicting patient prognosis. However, no predictive model has been constructed using the text content from coronary catheterization reports before.

Objective

To develop a deep learning model using text content from coronary catheterization reports to predict 5-year all-cause mortality and 5-year cardiovascular mortality for patients undergoing coronary angiography and to compare the performance of the model to the established clinical scores.

Method

This retrospective cohort study was conducted between January 1, 2006, and December 31, 2015. Patients admitted for coronary angiography were enrolled and followed up until August 2019. The main outcomes were 5-year all-cause mortality and 5-year cardiovascular mortality. In total, 11,576 coronary catheterization reports were collected. BioBERT (bidirectional encoder representations from transformers for biomedical text mining), which is a BERT-based model in the biomedical domain, was utilized to construct the model. The area under the receiver operating characteristic curve (AUC) was used to assess model performance. We also compared our results to the residual SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) score.

Results

The dataset was divided into the training (60%), validation (20%), and test (20%) sets. The mean age of the patients in each dataset was 65.5 ± 12.1, 65.4 ± 11.2, and 65.6 ± 11.2 years, respectively. A total of 1,411 (12.2%) patients died, and 664 (5.8%) patients died of cardiovascular causes within 5 years after coronary angiography. The best of our models had an AUC of 0.822 (95% CI, 0.790–0.855) for 5-year all-cause mortality, and an AUC of 0.858 (95% CI, 0.816–0.900) for 5-year cardiovascular mortality. We randomly selected 300 patients who underwent percutaneous coronary intervention (PCI), and our model outperformed the residual SYNTAX score in predicting 5-year all-cause mortality (AUC, 0.867 [95% CI, 0.813–0.921] vs. 0.590 [95% CI, 0.503–0.684]) and 5-year cardiovascular mortality (AUC, 0.880 [95% CI, 0.873–0.925] vs. 0.649 [95% CI, 0.535–0.764]), respectively, after PCI among these patients.

Conclusions

We developed a predictive model using text content from coronary catheterization reports to predict the 5-year mortality in patients undergoing coronary angiography. Since interventional cardiologists routinely write reports after procedures, our model can be easily implemented into the clinical setting.

Circulating miRNA-29b and Sclerostin Levels Correlate with Coronary Artery Calcification and Cardiovascular Events in Maintenance Hemodialysis Patients

Objective

Coronary artery calcification (CAC) is a common complication in end-stage renal disease (ESRD) patients undergoing maintenance hemodialysis (MHD), and the extent of CAC is a predominant predictor of cardiovascular outcomes in MHD patients. In this study, we sought to uncover the relationship between circulating miRNA-29b, sclerostin levels, CAC, and cardiovascular events (CVEs) in MHD patients.

Methods

This study recruited patients receiving MHD for at least three months in the Hainan General Hospital between January 2016 and June 2019, and all patients were followed up 24 months for CVEs. The serum level of sclerostin was determined by enzyme-linked immunosorbent assay (ELISA) and miRNA-29b expression by real-time qPCR (RT-qPCR). All patients received cardiac CT scans to evaluate CAC, and CAC scores were expressed in Agatston units. The MHD patients with CACs <100 were arranged into the CAC (<100) group, those with 100–400 CACs into the CAC (100–400) group, and those with CACs >400 into the CAC (>400) group. Net reclassification index (NRI) and integrated discrimination index (IDI) were calculated to assess the predictive performance of serum sclerostin level for the occurrence of CVEs.

Results

Compared with the CAC (<100) group, the CAC (>400) group had higher proportions of older patients, hypertension and diabetes mellitus patients, longer dialysis duration, higher mean arterial pressure (MAP), higher levels of high-sensitivity C-reactive protein (hs-CRP), alkaline phosphatase (ALP), and phosphate (P < 0.05). It was found that the CAC (100–400) and CAC (>400) groups exhibited higher serum levels of sclerostin but lower levels of miRNA-29b than the CAC (<100) group (P < 0.05) and the CAC (>400) group had a higher level of sclerostin and a lower level of miRNA-29b than the CAC (100–400) group (P < 0.05). The circulating level of miRNA-29b was negatively correlated with the serum level of sclerostin in MHD patients (r = −0.329, P < 0.01). The multivariate logistic regression analysis showed that hs-CRP, phosphate, sclerostin, and miRNA-29b were independent risk factors for CAC in MHD patients (P < 0.05, Table 2). ROC for prediction of CAC by sclerostin yielded 0.773 AUC with 95% CI 0.683–0.864 (P < 0.01). As depicted by Kaplan–Meier curves of CVE incidence in MHD patients according to median sclerostin (491.88 pg/mL) and median miRNA-29b (Ct = 25.15), we found that serum levels of sclerostin and miRNA-29b were correlated with the incidence of CVEs in MHD patients. When a new model was used to predict the incidence of CVEs, NRI 95% CI was 0.60 (0.16–1.03) (P < 0.05) and IDI 95% CI was 0.002 (−0.014 to 0.025) (P < 0.05), suggesting that sclerostin added into the old model could improve the prediction of the incidence of CVEs.

Conclusions

These data suggest that circulating miRNA-29b and sclerostin levels are correlated with CAC and incidence of CVEs in MHD patients. Higher sclerostin and lower miRNA-29b may serve as independent risk factors for the incidence of CVEs in MHD patients.

Lipid Droplet-a New Target in Ischemic Heart Disease

Lipid droplet (LD) is a kind of subcellular organelle, which originates from the endoplasmic reticulum (ER). LDs can move flexibly between other organelles and store energy in the cells. In recent years, LDs and lipid droplet-associated proteins have attracted added attention at home and abroad, especially in cardiovascular diseases. Cardiovascular diseases, especially ischemic heart disease (IHD), have always been the focus of attention because of their high morbidity and mortality. Atherosclerosis and myocardial remodeling are two important pathologic processes of IHD, and LDs and other organelles are involved in the development of the disease. The interaction between LDs and ER is involved in the formation of foam cells in atherosclerosis. And LDs, mitochondria, and lysosomes also affect the remodeling of cardiomyocytes by affecting ROS production and regulating PI3K/AKT pathways. In this article, we will review the role of LDs in IHD.