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Weijing L, Ximin F, Jianying S, Mengyun Z, Xuehua F, Yawei X, Liqiong H. Cardiac Shock Wave Therapy Ameliorates Myocardial Ischemia in Patients With Chronic Refractory Angina Pectoris: A Randomized Trial. Front Cardiovasc Med 2021; 8:664433. [PMID: 34368242 PMCID: PMC8333694 DOI: 10.3389/fcvm.2021.664433] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Cardiac shock wave therapy (CSWT) is a non-invasive new option for the treatment of chronic refractory angina pectoris (CRAP). This study aimed to evaluate the safety and efficiency of CSWT in the treatment of CRAP. Methods: Eighty-seven patients with CRAP were randomly allocated into CWST group (n = 46) and Control group (n = 41). Canadian Cardiovascular Society (CCS) grade of angina pectoris, Seattle Angina Questionnaire (SAQ) score, 6-min walk test (6MWT), weekly dosage of nitroglycerin, and myocardial perfusion on D-SPECT were determined at baseline and during the follow-up period. Adverse events were also evaluated. Results: CSWT was well-tolerated in the CSWT patients. CSWT significantly improved the CCS grade, SAQ score, and 6MWT (p < 0.05). Imaging examinations showed that the ischemic area was reduced after CSWT. However, no significant changes were observed in the Control group. Conclusions: CSWT may improve the myocardial perfusion and reduce clinical symptoms without increasing adverse effects in CRAP patients. It provides a non-invasive and safe clinical therapy for CRAP patients. Clinical Trial registration: www.ClinicalTrials.gov, identifier: NCT03398096.
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Affiliation(s)
- Liu Weijing
- Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Fan Ximin
- Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Shen Jianying
- Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Zhu Mengyun
- Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Fan Xuehua
- Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xu Yawei
- Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Hong Liqiong
- Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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2
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Storey KM, Wang J, Garberich RF, Bennett NM, Traverse JH, Arndt TL, Schmidt CW, Henry TD. Long-Term (3 Years) Outcomes of Ranolazine Therapy for Refractory Angina Pectoris (from the Ranolazine Refractory Registry). Am J Cardiol 2020; 129:1-4. [PMID: 32540170 DOI: 10.1016/j.amjcard.2020.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 05/04/2020] [Accepted: 05/12/2020] [Indexed: 11/19/2022]
Abstract
Ranolazine is approved for patients with chronic stable angina but has not been formally studied in patients with refractory angina pectoris (RAP). Patients with RAP have limited therapeutic options and significant limitations in their quality of life. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness of ranolazine in RAP patients in order to expand treatment options for this challenging patient population. Using an extensive prospective database, we enrolled 158 consecutive patients evaluated in a dedicated RAP clinic. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 12, 24, and 36 months. At 3 years, 95 (60%) patients remained on ranolazine. A ≥2 class improvement in angina was seen in 48% (38 of 80 patients with known Canadian Cardiovascular Society class) of those who remained on ranolazine. Discontinuation due to side effects, ineffectiveness, cost, and progression of disease were the principle reasons for discontinuation, but primarily occurred within the first year. In conclusion, ranolazine is an effective antianginal therapy at 3-year follow-up in patients with RAP and may reduce cardiac readmission.
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Affiliation(s)
| | - Julia Wang
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | - Noel M Bennett
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Jay H Traverse
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Theresa L Arndt
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio.
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3
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Bennett NM, Rutten-Ramos S, Arndt TL, Garberich RF, Traverse JH, Poulose AK, Mitchell P, Storey KM, Henry TD. Health Status and Quality of Life of Patients Enrolled in a Specialized Refractory Angina Clinic. ACTA ACUST UNITED AC 2019. [DOI: 10.21925/mplsheartjournal-d-18-00008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
As the mortality of coronary artery disease improves and the population ages, an increasing number of patients with refractory angina are not candidates for percutaneous or surgical revascularization. We evaluated the impact of a dedicated refractory angina clinic on quality of life. In 76 patients who completed the Medical Outcomes Study 36-Item Short-Form Health Survey and Seattle Angina Questionnaire at baseline and 1 year, the Medical Outcomes Study results showed the proportion of patients who rated their health as “good” or “excellent” more than doubled from baseline to 1 year (15.8% vs. 42.2%; P < .001). Similarly, the Seattle Angina Questionnaire score was significantly improved at 1 year compared to baseline (P = .025), as were angina stability (P = 0.017) and angina frequency (P = .010). In conclusion, treatment in a dedicated clinic is associated with improved quality of life in patients with refractory angina.
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Affiliation(s)
- Noel M. Bennett
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Stephanie Rutten-Ramos
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Theresa L. Arndt
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Ross F. Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Jay H. Traverse
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Anil K. Poulose
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Patricia Mitchell
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Katelyn M. Storey
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Timothy D. Henry
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
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4
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Hirai T, Grantham JA, Sapontis J, Cohen DJ, Marso SP, Lombardi W, Karmpaliotis D, Moses J, Nicholson WJ, Pershad A, Wyman RM, Spaedy A, Cook S, Doshi P, Federici R, Nugent K, Gosch KL, Spertus JA, Salisbury AC. Quality of Life Changes After Chronic Total Occlusion Angioplasty in Patients With Baseline Refractory Angina. Circ Cardiovasc Interv 2019; 12:e007558. [DOI: 10.1161/circinterventions.118.007558] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Taishi Hirai
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | - J. Aaron Grantham
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | | | - David J. Cohen
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | | | | | | | - Jeffrey Moses
- Columbia University, New York Presbyterian Hospital (D.K., J.M.)
| | | | - Ashish Pershad
- Banner Good Samaritan Medical Center, Phoenix, AZ (A.P.)
- Banner Heart, Mesa, AZ (A.P.)
| | | | | | - Stephen Cook
- Peacehealth Sacred Heart Medical Center, Springfield, OR (S.C.)
| | - Parag Doshi
- Alexian Brothers Medical Center, Chicago, IL (P.D.)
| | | | - Karen Nugent
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
| | - Kensey L. Gosch
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | - Adam C. Salisbury
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
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5
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Sharma R, Tradewell M, Kohl LP, Garberich RF, Traverse JH, Poulose A, Brilakis ES, Arndt T, Henry TD. Revascularization in "no option" patients with refractory angina: Frequency, etiology and outcomes. Catheter Cardiovasc Interv 2018; 92:1215-1219. [PMID: 30079551 DOI: 10.1002/ccd.27707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/16/2018] [Accepted: 05/30/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND A significant proportion of patients with complex, advanced coronary artery disease have refractory angina (RA) despite maximal pharmacological therapy and are deemed suboptimal candidates for revascularization. These patients are frequently termed "no-option" patients. However, despite this designation, many subsequently undergo coronary revascularization. We sought to determine the incidence, etiology and outcome of revascularization in "no-option" patients. METHODS AND RESULTS We examined a comprehensive, prospective RA database to identify 342 of 1363 (25.1%) patients who subsequently underwent revascularization after a median interval of 2.2 years from the "no-option" diagnosis. Coronary revascularization was achieved by percutaneous coronary intervention (PCI) (n = 274, 20.1%), coronary bypass graft surgery (n = 44, 3.2%) or both (n = 24, 1.8%). During a median follow-up of 5.1 years, patients who underwent revascularization had lower annual mortality (2% vs. 4.4%, P < .001). Detailed paired angiographic records were available for 181 PCI patients with a combined 302 lesions. Of these interventions, 48% were for a new lesion, 31% for an existing lesion and 21% for restenosis. The location was a native vessel in 77% and a bypass graft in 23%. CONCLUSIONS The "no-option" or non-revascularizable designation is frequently based on angiography at a single time-point. However, coronary artery disease is a progressive and dynamic process and new lesions often develop in such patients. Given the association between revascularization and better survival, careful consideration should be given to repeat revascularization in patients with refractory angina previously classified as "no-option".
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Affiliation(s)
- Rahul Sharma
- Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael Tradewell
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Louis P Kohl
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota.,Hennepin County Medical Center, Minneapolis, Minnesota
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jay H Traverse
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Anil Poulose
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Theresa Arndt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
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6
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Saini V, Garcia-Armesto S, Klemperer D, Paris V, Elshaug AG, Brownlee S, Ioannidis JPA, Fisher ES. Drivers of poor medical care. Lancet 2017; 390:178-190. [PMID: 28077235 DOI: 10.1016/s0140-6736(16)30947-3] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.
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Affiliation(s)
| | - Sandra Garcia-Armesto
- Aragon Agency for Research and Development, Zaragoza, Spain; Aragon Health Sciences Institute, Aragon, Spain
| | - David Klemperer
- Ostbayerische Technische Hochschule Regensburg, Fakultät Angewandte Sozial-und Gesundheitswissenschaften, Regensburg, Germany
| | - Valerie Paris
- Health Division, Organisation for Economic Co-operation and Development, Paris, France
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, University of Sydney, NSW, Australia
| | - Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Havard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, CA, USA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, CA, USA; Department of Statistics, Stanford University School of Humanities and Sciences and Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, USA
| | - Elliott S Fisher
- The Dartmouth Institute for Health Policy and Clinical Practice, Stanford University, Stanford, CA, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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7
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Giannini F, Aurelio A, Jabbour RJ, Ferri L, Colombo A, Latib A. The coronary sinus reducer: clinical evidence and technical aspects. Expert Rev Cardiovasc Ther 2016; 15:47-58. [DOI: 10.1080/14779072.2017.1270755] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Francesco Giannini
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Andrea Aurelio
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Cardiovascular Department, Casa di Cura Villa Verde, Taranto, Italy
| | - Richard J. Jabbour
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Luca Ferri
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Cardiovascular Department, Ospedale A. Manzoni, Lecco, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Azeem Latib
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
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8
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Nussinovitch U, Shtenberg G, Roguin A, Feld Y. A Novel Intra-aortic Device Designed for Coronary Blood Flow Amplification in Unrevascularizable Patients. J Cardiovasc Transl Res 2016; 9:315-20. [DOI: 10.1007/s12265-016-9702-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/26/2016] [Indexed: 01/09/2023]
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10
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Khan AR, Farid TA, Pathan A, Tripathi A, Ghafghazi S, Wysoczynski M, Bolli R. Impact of Cell Therapy on Myocardial Perfusion and Cardiovascular Outcomes in Patients With Angina Refractory to Medical Therapy: A Systematic Review and Meta-Analysis. Circ Res 2016; 118:984-93. [PMID: 26838794 DOI: 10.1161/circresaha.115.308056] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 01/13/2016] [Indexed: 12/15/2022]
Abstract
RATIONALE The effect of stem/progenitor cells on myocardial perfusion and clinical outcomes in patients with refractory angina remains unclear because studies published to date have been small phase I-II trials. OBJECTIVE We performed a meta-analysis of randomized controlled trials to evaluate the effect of cell-based therapy in patients with refractory angina who were ineligible for coronary revascularization. METHODS AND RESULTS Several data sources were searched from inception to September 2015, which yielded 6 studies. The outcomes pooled were indices of angina (anginal episodes, Canadian Cardiovascular Society angina class, exercise tolerance, and antianginal medications), myocardial perfusion, and clinical end points. We combined the reported clinical outcomes (myocardial infarction, cardiac-related hospitalization, and mortality) into a composite end point (major adverse cardiac events). Mean difference (MD), standardized mean differences, or odds ratio were calculated to assess relevant outcomes. Our analysis shows an improvement in anginal episodes (MD, -7.81; 95% confidence interval [CI], -15.22 to -0.41), use of antianginal medications (standardized MD, -0.59; 95% CI, -1.03 to -0.14), Canadian Cardiovascular Society class (MD, -0.58; 95% CI, -1.00 to -0.16), exercise tolerance (standardized MD, 0.331; 95% CI, 0.08 to 0.55), and myocardial perfusion (standardized MD, -0.49; 95% CI, -0.76 to -0.21) and a decreased risk of major adverse cardiac events (odds ratio, 0.49; 95% CI, 0.25 to 0.98) and arrhythmias (odds ratio, 0.25; 95% CI, 0.06 to 0.98) in cell-treated patients when compared with patients on maximal medical therapy. CONCLUSIONS The present meta-analysis indicates that cell-based therapies are not only safe but also lead to an improvement in indices of angina, relevant clinical outcomes, and myocardial perfusion in patients with refractory angina. These encouraging results suggest that larger, phase III randomized controlled trials are in order to conclusively determine the effect of stem/progenitor cells in refractory angina.
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Affiliation(s)
- Abdur Rahman Khan
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Talha A Farid
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Asif Pathan
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Avnish Tripathi
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Shahab Ghafghazi
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Marcin Wysoczynski
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Roberto Bolli
- From the Institute of Molecular Cardiology, University of Louisville, KY.
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11
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Abstract
With improvements in survival from coronary artery disease (CAD) and an ageing population, refractory angina (RA) is becoming an increasingly common clinical problem facing clinicians in routine clinical practice. These patients experience chronic symptoms in the context of CAD, characterised by angina-type pain, which is uncontrolled despite optimal pharmacological, interventional and surgical therapy. Although mortality rates are no worse in this cohort, patients experience a significantly impaired quality of life with disproportionately high utilisation of healthcare services. It has been increasingly recognised that the needs of RA patients are multifactorial and best provided by specialist multi-disciplinary units. In this review, we consider the variety of therapies available to clinicians in the management of RA and discuss the promise of novel treatments.
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Affiliation(s)
- Kevin Cheng
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Heart Science, National Heart and Lung Institute, Imperial College London, London, UK
| | - Paul Sainsbury
- Department of Cardiology, Bradford Royal Infirmary, Bradford, UK
| | - Michael Fisher
- Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust and Royal Liverpool and Broadgreen NHS Trust, Liverpool, UK
| | - Ranil de Silva
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Vascular Science, National Heart and Lung Institute, Imperial College London, London, UK
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12
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Kaller M, Faber L, Bogunovic N, Horstkotte D, Burchert W, Lindner O. Cardiac shock wave therapy and myocardial perfusion in severe coronary artery disease. Clin Res Cardiol 2015; 104:843-9. [PMID: 25893568 PMCID: PMC4580718 DOI: 10.1007/s00392-015-0853-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 03/31/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ultrasound guided cardiac shock wave therapy (CSWT) is a noninvasive therapeutic option in the treatment of chronic-refractory angina. Clinical trials have shown that CSWT reduces angina symptoms, improves regional systolic function, LV ejection fraction, myocardial perfusion and quality of life parameters. Absolute measurements of myocardial perfusion before and after CSWT have not been performed so far. METHODS AND RESULTS We studied a total of 21 CCS III patients with history of CAD and multiple interventions who suffered from disabling angina despite individually optimized medical therapy. An N-13 NH3 PET perfusion scan under adenosine was performed before and after CSWT treatment. CSWT was well tolerated in all patients. Absolute perfusion under adenosine of the global left-ventricular myocardium did not change under therapy or minimal coronary resistance. The treated segments, however, showed in terms of both perfusion and resistance a mild but significant improvement, by 11 and 15 %, respectively, whereas no change could be observed in the remote segments. Considering a threshold of increased perfusion of 5 %, 10 (77 %) out of 13 patients with a better target perfusion improved in their CCS class, whereas 3 (43 %) out of 7 patients without improved target perfusion improved in their CCS class too. CONCLUSION Standard CSWT has the potential to improve myocardial perfusion of the therapy zone and clinical CAD symptomatology without affecting global myocardial perfusion. As a noninvasive and well tolerated therapeutic option, these data suggest the use of CSWT in patients with end-stage CAD.
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Affiliation(s)
- M Kaller
- Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr-University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - L Faber
- Clinic for Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - N Bogunovic
- Clinic for Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - D Horstkotte
- Clinic for Cardiology, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - W Burchert
- Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr-University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany
| | - Oliver Lindner
- Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine-Westphalia, University Hospital of the Ruhr-University Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Germany.
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13
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Verheye S, Jolicœur EM, Behan MW, Pettersson T, Sainsbury P, Hill J, Vrolix M, Agostoni P, Engstrom T, Labinaz M, de Silva R, Schwartz M, Meyten N, Uren NG, Doucet S, Tanguay JF, Lindsay S, Henry TD, White CJ, Edelman ER, Banai S. Efficacy of a device to narrow the coronary sinus in refractory angina. N Engl J Med 2015; 372:519-27. [PMID: 25651246 PMCID: PMC6647842 DOI: 10.1056/nejmoa1402556] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Many patients with coronary artery disease who are not candidates for revascularization have refractory angina despite standard medical therapy. The balloon-expandable, stainless steel, hourglass-shaped, coronary-sinus reducing device creates a focal narrowing and increases pressure in the coronary sinus, thus redistributing blood into ischemic myocardium. METHODS We randomly assigned 104 patients with Canadian Cardiovascular Society (CCS) class III or IV angina (on a scale from I to IV, with higher classes indicating greater limitations on physical activity owing to angina) and myocardial ischemia, who were not candidates for revascularization, to implantation of the device (treatment group) or to a sham procedure (control group). The primary end point was the proportion of patients with an improvement of at least two CCS angina classes at 6 months. RESULTS A total of 35% of the patients in the treatment group (18 of 52 patients), as compared with 15% of those in the control group (8 of 52), had an improvement of at least two CCS angina classes at 6 months (P=0.02). The device was also associated with improvement of at least one CCS angina class in 71% of the patients in the treatment group (37 of 52 patients), as compared with 42% of those in the control group (22 of 52) (P=0.003). Quality of life as assessed with the use of the Seattle Angina Questionnaire was significantly improved in the treatment group, as compared with the control group (improvement on a 100-point scale, 17.6 vs. 7.6 points; P=0.03). There were no significant between-group differences in improvement in exercise time or in the mean change in the wall-motion index as assessed by means of dobutamine echocardiography. At 6 months, 1 patient in the treatment group had had a myocardial infarction; in the control group, 1 patient had died and 3 had had a myocardial infarction. CONCLUSIONS In this small clinical trial, implantation of the coronary-sinus reducing device was associated with significant improvement in symptoms and quality of life in patients with refractory angina who were not candidates for revascularization. (Funded by Neovasc; COSIRA ClinicalTrials.gov number, NCT01205893.).
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Affiliation(s)
- Stefan Verheye
- Antwerp Cardiovascular Center, ZNA Middelheim, Antwerp, Belgium
| | | | | | | | | | | | | | | | | | | | - Ranil de Silva
- National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust. London, UK
| | | | - Nathalie Meyten
- Antwerp Cardiovascular Center, ZNA Middelheim, Antwerp, Belgium
| | | | | | | | | | | | - Christopher J. White
- The John Ochsner Heart & Vascular Institute, Ochsner Clinical School, University of Queensland, New Orleans, LA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, MIT, Cambridge, MA USA, and Cardiovascular Division Brigham and Women’s Hospital, Harvard Medical School, Boston MA
| | - Shmuel Banai
- Tel Aviv Medical Center, The Tel Aviv University Medical School, Tel Aviv, Israel
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Kindzelski BA, Zhou Y, Horvath KA. Transmyocardial revascularization devices: technology update. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 8:11-9. [PMID: 25565905 PMCID: PMC4274152 DOI: 10.2147/mder.s51591] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Transmyocardial laser revascularization (TMR) emerged as treatment modality for patients with diffuse coronary artery disease not amendable to percutaneous or surgical revascularization. The procedure entails the creation of laser channels within ischemic myocardium in an effort to better perfuse these areas. Currently, two laser devices are approved by the US Food and Drug Administration for TMR – holmium:yttrium–aluminum–garnet and CO2. The two devices differ in regard to energy outputs, wavelengths, ability to synchronize with the heart cycle, and laser–tissue interactions. These differences have led to studies showing different efficacies between the two laser devices. Over 50,000 procedures have been performed worldwide using TMR. Improvements in angina stages, quality of life, and perfusion of the myocardium have been demonstrated with TMR. Although several mechanisms for these improvements have been suggested, evidence points to new blood vessel formation, or angiogenesis, within the treated myocardium, as the major contributory factor. TMR has been used as sole therapy and in combination with coronary artery bypass grafting. Clinical studies have demonstrated that TMR is both safe and effective in angina relief long term. The objective of this review is to present the two approved laser devices and evidence for the safety and efficacy of TMR, along with future directions with this technology.
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Affiliation(s)
- Bogdan A Kindzelski
- Cardiothoracic Surgery Research Program, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yifu Zhou
- Cardiothoracic Surgery Research Program, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Keith A Horvath
- Cardiothoracic Surgery Research Program, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Bennett NM, Iyer V, Arndt TL, Garberich RF, Traverse JH, Johnson RK, Poulose AK, Lips A, Morgan JM, Henry TD. Ranolazine refractory angina registry: 1-year results. Crit Pathw Cardiol 2014; 13:96-98. [PMID: 25062392 DOI: 10.1097/hpc.0000000000000022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Patients with refractory angina (RA) have limited therapeutic options and significant limitations in their quality of life. Ranolazine is approved for patients with chronic stable angina but has not been studied in patients with RA. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness in RA patients. In a dedicated RA clinic using an extensive prospective database, 100 patients were enrolled. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 1, 6, and 12 months. Overall 43% of patients had a ≥2 class improvement in angina. At 1 year, 57% patients remained on ranolazine (91.2%; 500 mg BID), including 58% with a ≥2 class improvement in angina. Reasons for discontinuation included: side effects (n = 16), major adverse cardiac events (n = 10), cost (n = 5), ineffective (n = 6), cost and ineffective (n = 3), and unknown (n = 3). In conclusion, ranolazine is an effective antianginal therapy in patients with RA; still at 1 year only 57% of patients remained on ranolazine because of side effects, suboptimal effectiveness, cost, or progression of disease.
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Affiliation(s)
- Noel M Bennett
- From the *Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; †University at Buffalo, Buffalo, NY; and ‡Cedars-Sinai Heart Institute, Los Angeles, CA
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Hossne NA, Cruz E, Buffolo E, Coimbra ACTDSMD, Machado J, Goldenberg RCDS, Regazzi G, Azevedo S, Invitti AL, Rodrigues Branco JN, Rodrigues de Oliveira JS, Stolf NAG, Miller LW, Sanberg PR. Long-Term and Sustained Therapeutic Results of a Specific Promonocyte Cell Formulation in Refractory Angina: ReACT(®) (Refractory Angina Cell Therapy) Clinical Update and Cost-Effective Analysis. Cell Transplant 2014; 24:955-70. [PMID: 24819720 DOI: 10.3727/096368914x681595] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Mononuclear stem cells have been studied for their potential in myocardial ischemia. In our previous published article, ReACT(®) phase I/II clinical trial, our results suggest that a certain cell population, promonocytes, directly correlated with the perceived angiogenesis in refractory angina patients. This study is ReACT's clinical update, assessing long-term sustained efficacy. The ReACT phase IIA/B noncontrolled, open-label, clinical trial enrolled 14 patients with refractory angina and viable ischemic myocardium, without ventricular dysfunction, who were not suitable for myocardial revascularization. The procedure consisted of direct myocardial injection of a specific mononuclear cell formulation, with a certain percentage of promonocytes, in a single series of multiple injections (24-90; 0.2 ml each) into specific areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification (CCSAC) improvement at the 12-month follow-up and ischemic area reduction (scintigraphic analysis) at the 12-month follow-up, in correlation with ReACT's formulation. A recovery index (for patients with more than 1 year follow-up) was created to evaluate CCSAC over time, until April 2011. Almost all patients presented progressive improvement in CCSAC beginning 3 months (p=0.002) postprocedure, which was sustained at the 12-month follow-up (p=0.002), as well as objective myocardium ischemic area reduction at 6 months (decrease of 15%, p<0.024) and 12 months (decrease of 100%, p<0.004) The recovery index (n=10) showed that the patients were graded less than CCSAC 4 for 73.9 ± 24.2% over a median follow-up time of 46.8 months. After characterization, ReACT's promonocyte concentration suggested a positive correlation with CCSAC improvement (r=-0.575, p=0.082). Quality of life (SF-36 questionnaire) improved significantly in almost all domains. Cost-effectiveness analysis showed decrease in angina-related direct costs. Refractory angina patients presented a sustained long-term improvement in CCSAC and myocardium ischemic areas after the procedure. The long-term follow-up and strong improvement in quality of life reinforce effectiveness. Promonocytes may play a key role in myocardial neoangiogenesis. ReACT dramatically decreased direct costs.
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Affiliation(s)
- Nelson Americo Hossne
- Cardiovascular Surgery Division, Surgery Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
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Henry TD, Satran D, Jolicoeur EM. Treatment of refractory angina in patients not suitable for revascularization. Nat Rev Cardiol 2013; 11:78-95. [DOI: 10.1038/nrcardio.2013.200] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Stem Cell Therapy Is a Promising Tool for Refractory Angina: A Meta-analysis of Randomized Controlled Trials. Can J Cardiol 2013; 29:908-14. [DOI: 10.1016/j.cjca.2012.12.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 11/19/2012] [Accepted: 12/04/2012] [Indexed: 12/26/2022] Open
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Henry TD, Satran D, Hodges JS, Johnson RK, Poulose AK, Campbell AR, Garberich RF, Bart BA, Olson RE, Boisjolie CR, Harvey KL, Arndt TL, Traverse JH. Long-term survival in patients with refractory angina. Eur Heart J 2013; 34:2683-8. [DOI: 10.1093/eurheartj/eht165] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Jolicœur EM, Banai S, Henry TD, Schwartz M, Doucet S, White CJ, Edelman E, Verheye S. A phase II, sham-controlled, double-blinded study testing the safety and efficacy of the coronary sinus reducer in patients with refractory angina: study protocol for a randomized controlled trial. Trials 2013; 14:46. [PMID: 23413981 PMCID: PMC3599995 DOI: 10.1186/1745-6215-14-46] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 01/21/2013] [Indexed: 01/06/2023] Open
Abstract
Background A growing population of patients lives with severe coronary artery disease not amenable to coronary revascularization and with refractory angina despite optimal medical therapy. Percutaneous reduction of the coronary sinus is an emerging treatment for myocardial ischemia that increases coronary sinus pressure to promote a transcollateral redistribution of coronary artery in-flow from nonischemic to ischemic subendocardial territories. A first-in-man study has demonstrated that the percutaneous reduction of the coronary sinus can be performed safely in such patients. The COSIRA trial seeks to assess whether a percutaneous reduction of the coronary sinus can improve the symptoms of refractory angina in patients with limited revascularization options. Methods/Design The COSIRA trial is a phase II double-blind, sham-controlled, randomized parallel trial comparing the percutaneously implanted coronary sinus Reducer (Neovasc Inc, Richmond, BC, Canada) to a sham implantation in 124 patients enrolled in Canada, Belgium, England, Scotland, Sweden and Denmark. All patients need to have stable Canadian Cardiovascular Society (CCS) class III or IV angina despite optimal medical therapy, with evidence of reversible ischemia related to disease in the left coronary artery, and a left ventricular ejection fraction >25%. Participants experiencing an improvement in their angina ≥2 CCS classes six months after the randomization will meet the primary efficacy endpoint. The secondary objective of this trial is to test whether coronary sinus Reducer implantation will improve left ventricular ischemia, as measured by the improvement in dobutamine echocardiogram wall motion score index and in time to 1 mm ST-segment depression from baseline to six-month post-implantation. Discussion Based on previous observations, the COSIRA is expected to provide a significant positive result or an informative null result upon which rational development decisions can be based. Patient safety is a central concern and extensive monitoring should allow an appropriate investigation of the safety related to the coronary sinus Reducer. Trial registration ClinicalTrials.gov identifier - NCT01205893.
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Affiliation(s)
- E Marc Jolicœur
- Montreal Heart Institute, Université de Montréal, 5000 Bélanger Street East, Montréal, Québec Q H1T 1C8, Canada.
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Zipes DP, Svorkdal N, Berman D, Boortz-Marx R, Henry T, Lerman A, Ross E, Turner M, Irwin C. Spinal cord stimulation therapy for patients with refractory angina who are not candidates for revascularization. Neuromodulation 2012; 15:550-8; discussion 558-9. [PMID: 22494013 DOI: 10.1111/j.1525-1403.2012.00452.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the safety and efficacy of spinal cord stimulation (SCS) for refractory angina. MATERIALS AND METHODS This multicenter, randomized, single-blind, controlled trial evaluated SCS in two patient groups: high stimulation (HS) (treatment) and low stimulation (LS) (control). The HS group controlled SCS with a programmer for a minimum of two hours four times daily. The LS group received SCS therapy above the paresthesia threshold for one min once daily. The primary efficacy endpoint was number of angina attacks recorded by patients at six months. The primary safety endpoint was the major adverse cardiac event (MACE) rate at six months. RESULTS Due to slow enrollment, a futility analysis was performed, resulting in early termination of the study. Sixty-eight patients were randomized after implantation. Mean change in angina attacks per day from baseline to six months was -1.19 ± 2.13 (HS) and -1.29 ± 1.66 (LS). The difference from baseline was significant within each group (both p < 0.001) but not between groups (p = 0.45). Total exercise time and time to angina onset increased significantly from baseline to six months within each group (both p = 0.02 and 0.002) but not between groups (p = 0.52 and 0.51). MACE was similar between groups. CONCLUSION Although this study was terminated early, the results obtained at six months suggest that SCS (HS) is not more effective than the control (LS) in patients with refractory angina.
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Affiliation(s)
- Douglas P Zipes
- Indiana University School of Medicine, Indianapolis, IN 46202-4800, USA.
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22
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Li X, van der Meer JJ, van der Loos CM, Ploegmakers HJP, de Boer OJ, de Winter RJ, van der Wal AC. Microvascular endoglin (CD105) expression correlates with tissue markers for atherosclerotic plaque vulnerability in an ageing population with multivessel coronary artery disease. Histopathology 2012; 61:88-97. [PMID: 22463585 DOI: 10.1111/j.1365-2559.2011.04166.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS Vulnerable atherosclerotic plaques are lesions with a high propensity to develop plaque disruption and superimposed thrombosis. No systematic studies have been carried out on tissue markers for plaque vulnerability throughout the entire coronary artery system at the end stages of coronary atherosclerosis. METHODS AND RESULTS Nine autopsied patients (mean age 77 years) with angiographically severe trivascular coronary atherosclerosis were selected for this study. All visible lesions in postmortem coronary angiograms (n = 125) were histologically and immunohistochemically screened for the presence of intraplaque haemorrhages (activated) microvessels and inflammatory infiltrates. Intraplaque haemorrhages were observed in 76/125 plaques (61%). Chronic inflammation was found superficially in 59/125 plaques (47%) and deeply inside the plaque tissue in 103/125 plaques (83%). Microvessels were found in 100/125 lesions (80%), of which 58% showed endothelial expression of the vascular activation marker CD105. Moreover, microvascular CD105 positivity correlated positively with plaque haemorrhage and deeply seated plaque inflammation. CONCLUSIONS Plaque inflammation and haemorrhages can be found at a high frequency throughout the coronary artery system of elderly patients with multivessel coronary atherosclerosis. Microvascular expression of endoglin (CD105), which correlates positively with both of these features of plaque vulnerability, can serve as a marker of the risk of developing coronary thrombotic complications.
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Affiliation(s)
- Xiaofei Li
- Department of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Jolicoeur EM, Cartier R, Henry TD, Barsness GW, Bourassa MG, McGillion M, L'Allier PL. Patients With Coronary Artery Disease Unsuitable for Revascularization: Definition, General Principles, and a Classification. Can J Cardiol 2012; 28:S50-9. [DOI: 10.1016/j.cjca.2011.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 10/26/2011] [Accepted: 10/26/2011] [Indexed: 01/09/2023] Open
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Losordo DW, Henry TD, Davidson C, Sup Lee J, Costa MA, Bass T, Mendelsohn F, Fortuin FD, Pepine CJ, Traverse JH, Amrani D, Ewenstein BM, Riedel N, Story K, Barker K, Povsic TJ, Harrington RA, Schatz RA. Intramyocardial, autologous CD34+ cell therapy for refractory angina. Circ Res 2011; 109:428-36. [PMID: 21737787 DOI: 10.1161/circresaha.111.245993] [Citation(s) in RCA: 392] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
RATIONALE A growing number of patients with coronary disease have refractory angina. Preclinical and early-phase clinical data suggest that intramyocardial injection of autologous CD34+ cells can improve myocardial perfusion and function. OBJECTIVE Evaluate the safety and bioactivity of intramyocardial injections of autologous CD34+ cells in patients with refractory angina who have exhausted all other treatment options. METHODS AND RESULTS In this prospective, double-blind, randomized, phase II study (ClinicalTrials.gov identifier: NCT00300053), 167 patients with refractory angina received 1 of 2 doses (1×10(5) or 5×10(5) cells/kg) of mobilized autologous CD34+ cells or an equal volume of diluent (placebo). Treatment was distributed into 10 sites of ischemic, viable myocardium with a NOGA mapping injection catheter. The primary outcome measure was weekly angina frequency 6 months after treatment. Weekly angina frequency was significantly lower in the low-dose group than in placebo-treated patients at both 6 months (6.8±1.1 versus 10.9±1.2, P=0.020) and 12 months (6.3±1.2 versus 11.0±1.2, P=0.035); measurements in the high-dose group were also lower, but not significantly. Similarly, improvement in exercise tolerance was significantly greater in low-dose patients than in placebo-treated patients (6 months: 139±151 versus 69±122 seconds, P=0.014; 12 months: 140±171 versus 58±146 seconds, P=0.017) and greater, but not significantly, in the high-dose group. During cell mobilization and collection, 4.6% of patients had cardiac enzyme elevations consistent with non-ST segment elevation myocardial infarction. Mortality at 12 months was 5.4% in the placebo-treatment group with no deaths among cell-treated patients. CONCLUSIONS Patients with refractory angina who received intramyocardial injections of autologous CD34+ cells (10(5) cells/kg) experienced significant improvements in angina frequency and exercise tolerance. The cell-mobilization and -collection procedures were associated with cardiac enzyme elevations, which will be addressed in future studies.
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Affiliation(s)
- Douglas W Losordo
- Division of Cardiology, Northwestern Memorial Hospital, Northwestern University, Chicago, IL 60611, USA.
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Ruiz-Garcia J, Lerman A. Cardiac shock-wave therapy in the treatment of refractive angina pectoris. Interv Cardiol 2011. [DOI: 10.2217/ica.11.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Williams B, Menon M, Satran D, Hayward D, Hodges JS, Burke MN, Johnson RK, Poulose AK, Traverse JH, Henry TD. Patients with coronary artery disease not amenable to traditional revascularization: prevalence and 3-year mortality. Catheter Cardiovasc Interv 2010; 75:886-91. [PMID: 20432394 DOI: 10.1002/ccd.22431] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To determine the contemporary prevalence of and mortality in patients with coronary artery disease (CAD) not amenable to revascularization. BACKGROUND A growing number of patients have severe CAD with ongoing angina despite optimal medical therapy which is not amenable to traditional revascularization. Limited data exist on contemporary prevalence and outcome for these patients. METHODS Clinical and angiographic data were reviewed for 493 consecutive patients undergoing coronary angiography and revascularization if indicated. Patients were categorized into six groups: (1) normal coronary arteries, (2) CAD <70%, (3) CAD >70% with complete revascularization by percutaneous intervention or coronary artery bypass grafting, (4) CAD >70% with partial revascularization, (5) CAD >70% treated medically, and (6) CAD >70% on optimal medical therapy with no revascularization option. All-cause mortality at 3 years was determined. RESULTS Prevalence for groups 1-6 was 14.8, 19.5, 36.9, 12.8, 9.3, and 6.7%, respectively. Three-year mortality increased with angiographic severity of CAD: 2.7, 6.3, 8.2, 12.7, 17.4, and 15.2%, respectively. Patients with incomplete revascularization (groups 4-6, n = 142) had higher mortality than completely revascularized patients (groups 1-3, n = 351): 14.8 vs. 6.6% (P = 0.004). CONCLUSIONS In a contemporary series of patients undergoing coronary angiography, 28.8% (142/493) of patients had significant CAD and did not undergo complete revascularization, including 12.8% partially revascularized, 9.3% managed medically, and 6.7% with "no-option." These patients had higher mortality at 3 years (14.8 vs. 6.6%, P = 0.004) when compared with completely revascularized patients.
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Affiliation(s)
- Benjamin Williams
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota 55407, USA
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Colivicchi F, Tubaro M, Mocini D, Genovesi Ebert A, Strano S, Melina G, Uguccioni M, Santini M. Full-dose atorvastatin versus conventional medical therapy after non-ST-elevation acute myocardial infarction in patients with advanced non-revascularisable coronary artery disease. Curr Med Res Opin 2010; 26:1277-84. [PMID: 20367555 DOI: 10.1185/03007991003751496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS This study tested the hypothesis that the addition of full-dose atorvastatin (80 mg/day) to conventional medical treatment could reduce ischaemic recurrences after non-ST-elevation acute myocardial infarction (NSTE-AMI) in patients with severe and diffuse coronary artery disease (CAD) not amenable to any form of mechanical revascularisation. METHODS AND RESULTS The study was an open-label, randomised, controlled, blinded end-point classification trial, employing the PROBE (Prospective Open Treatment and Blinded End Point Evaluation) design. A total of 290 patients (mean age 74.6 +/- 9.6 years) with NSTE-AMI and angiographic evidence of severe and diffuse CAD, not amenable to revascularisation by either coronary surgery or angioplasty, were randomised to atorvastatin 80 mg/day (n = 144) or conventional medical treatment (n = 146). A primary end point event (combination of cardiovascular death, non-fatal acute myocardial reinfarction and disabling stroke within 12 months of randomisation) occurred in 16.0% of patients treated with atorvastatin 80 mg/day and in 26.7% of patients receiving conventional treatment (HR 0.56; 95% CI 0.33-0.93, p = 0.027). The study was not blinded. Consequently, a bias in the assessment of clinical outcome cannot be completely excluded. CONCLUSIONS In conclusion, when compared with a conventional treatment strategy, full-dose therapy with atorvastatin 80 mg/day provides greater protection against ischaemic recurrences after NSTE-AMI in patients with severe, diffuse, non-revascularisable CAD.
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Affiliation(s)
- Furio Colivicchi
- Cardiology Division, Cardiovascular Department, San Filippo Neri Hospital, Rome, Italy.
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Brandão SMG, Schettert IT, César LAM, Krieger JE, de Oliveira SA, Stolf NAG, Gowdak LHW. Clinical profile of patients enroled in a cell therapy trial for severe coronary artery disease. J Clin Nurs 2010; 19:440-6. [PMID: 20500284 DOI: 10.1111/j.1365-2702.2009.03045.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To compare the clinical profile of patients included in a clinical trial of autologous bone marrow cells as an adjunctive therapy to coronary artery bypass grafting with that of patients undergoing routine coronary artery bypass grafting. BACKGROUND The therapeutic potential of autologous bone marrow cells has been explored in the treatment of severe coronary artery disease. There are few data regarding the clinical and socio-economic profile of patients included in clinical trials using bone marrow cell. DESIGN Case-control study. METHOD Sixty-seven patients (61 SD 9) years, 82% men) with multivessel coronary artery disease were divided into two groups: patients in the bone marrow cell group (n = 34) underwent incomplete coronary artery bypass grafting + intramyocardial injection of autologous bone marrow cells (lymphomonocytic fraction -2.0 (SD 0.2 x 10(8)) cells/patient) in the ischaemic, non-revascularised myocardium, whereas patients in the coronary artery bypass grafting group (n = 33) underwent routine bypass surgery. Demographics, socio-economic status, clinical and echocardiographic data were collected. Statistical analysis included the Fisher's exact test (categorical variables) and the Student's t-test (continuous variables). RESULTS There were no significant differences between groups regarding age, gender, BMI, heart rate, blood pressure and echo data. There was a greater prevalence of obesity (65 vs. 33%; OR = 3.7 [1.3-10.1]), of previous myocardial infarction (68 vs. 39%; OR = 3.2 [1.2-8.8]) and prior revascularisation procedures (59 vs. 24%; OR = 4.5 [1.6-12.7]) in the autologous bone marrow cells group and of smokers in the coronary artery bypass grafting group (51 vs. 23%; OR = 3.5 [1.2-10.4]). CONCLUSIONS Patients included in this clinical trial of autologous bone marrow cells for severe coronary artery disease presented a greater prevalence of myocardial revascularisation procedures, indicating a more severe clinical presentation of the disease. Fewer smokers in this group could be attributable to life style changes after previous cardiovascular events and/or interventions. RELEVANCE TO CLINICAL PRACTICE The knowledge of the clinical profile of patients included in cell therapy trials may help researchers in the identification of patients that may be enroled in future clinical trials of this new therapeutic strategy.
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Affiliation(s)
- Sara M G Brandão
- Heart Institute (InCor), University of São Paulo Medical School-Av. Dr. Enéas de Carvalho Aguiar, São Paulo/SP, Brazil.
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Hossne NA, Invitti AL, Buffolo E, Azevedo S, Rodrigues de Oliveira JS, Stolf NG, Cruz LE, Sanberg PR. Refractory angina cell therapy (ReACT) involving autologous bone marrow cells in patients without left ventricular dysfunction: a possible role for monocytes. Cell Transplant 2009; 18:1299-310. [PMID: 20149298 DOI: 10.3727/096368909x484671] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Autologous bone marrow mononuclear cell (BMMC) transplantation has emerged as a potential therapeutic option for refractory angina patients. Previous studies have shown conflicting myocardium reperfusion results. The present study evaluated safety and efficacy of CellPraxis Refractory Angina Cell Therapy Protocol (ReACT), in which a specific BMMC formulation was administered as the sole therapy for these patients. The phase I/IIa noncontrolled, open label, clinical trial, involved eight patients with refractory angina and viable ischemic myocardium, without left ventricular dysfunction and who were not suitable for conventional myocardial revascularization. ReACT is a surgical procedure involving a single series of multiple injections (40-90 injections, 0.2 ml each) into ischemic areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification (CCSAC) improvement at 18 months follow-up and myocardium ischemic area reduction (assessed by scintigraphic analysis) at 12 months follow-up, in correlation with a specific BMMC formulation. Almost all patients presented progressive improvement in angina classification beginning 3 months (p = 0.008) postprocedure, which was sustained at 18 months follow-up (p = 0.004), as well as objective myocardium ischemic area reduction at 12 months (decrease of 84.4%, p < 0.004). A positive correlation was found between monocyte concentration and CCSAC improvement (r = -0.759, p < 0.05). Improvement in CCSAC, followed by correlated reduction in scintigraphic myocardium ischemic area, strongly suggests neoangiogenesis as the main stem cell action mechanism. The significant correlation between number of monocytes and improvement strongly supports a cell-related effect of ReACT. ReACT appeared safe and effective.
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Affiliation(s)
- Nelson Americo Hossne
- Cardiovascular Surgery Division, Surgery Department, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil.
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Abstract
Imaging myocardial angiogenesis presents a major technical challenge because the ideal spatial resolution required is substantially higher than that available with standard X-ray angiography and nuclear medicine imaging. Moreover, these clinical imaging methods are currently inadequate (because of insufficient resolution) for clinical trials of angiogenic agents for the treatment of ischemic heart disease. Specialized techniques in MRI, ultrasonography, echocardiography and CT that are under development might provide improved means of imaging myocardial angiogenesis. Molecular imaging technologies are also being developed to improve resolution and to provide a better mechanistic insight into angiogenic therapies for ischemic heart diseases. This Review examines advanced methods for imaging angiogenesis. These technologies might soon permit data to be obtained directly from scientific studies and clinical trials.
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Current World Literature. Curr Opin Support Palliat Care 2008; 2:288-91. [DOI: 10.1097/spc.0b013e32831d29c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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