1
|
The Role of Ranolazine for the Treatment of Residual Angina beyond the Percutaneous Coronary Revascularization. J Clin Med 2020; 9:jcm9072110. [PMID: 32635532 PMCID: PMC7408663 DOI: 10.3390/jcm9072110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Despite a successful percutaneous coronary intervention (PCI), several studies reported that the recurrence of angina after revascularization, even complete, is a particularly frequent occurrence in the first year after PCI. METHODS The aim was to evaluate the efficacy of treatment with ranolazine in addition to conventional anti-ischemic therapy in patients who underwent coronary angiography for persistent/recurrent angina after PCI and residual ischemia only due to small branches not suitable for further revascularization. Forty-nine consecutive patients were included in our registry, adding the ranolazine (375 mg b.i.d) to optimal medical therapy (OMT). The Exercise ECG Test (EET) was performed in all patients before to start the therapy (baseline BL) and at 30 days (T1) after enrollment. RESULTS The average duration of the exercise was increased after the therapy with ranolazine comparing to baseline (RG 9'1'' ± 2' versus BL 8'10'' ± 2', p = 0.01). Seven (14.3%) patients after receiving ranolazine had not crossed the threshold of six minutes (75 watts) compared to 20 (40.8%) of BL (p = 0.0003). Stress angina appeared more frequently at BL than at 30 days (T1 4.1% versus BL 16.3%, p = 0.04) as well as exercise-induced arrhythmias (BL 30.6% versus T1 14.3%, p = 0.05). CONCLUSIONS The addition of ranolazine to standard anti-ischemic therapy showed a significant improvement in EET results after one month of therapy, including reduced exercise angina, increased exercise tolerance, and reduced exercise arrhythmias.
Collapse
|
2
|
Turgeon RD. Treating Angina in Women: Improving Options and Outcomes. J Womens Health (Larchmt) 2019; 28:561-562. [DOI: 10.1089/jwh.2018.7565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
3
|
Mehta PK, Sharma S, Minissian M, Harsch MR, Martinson M, Nyman JA, Shaw LJ, Bairey Merz CN, Wenger NK. Ranolazine Reduces Angina in Women with Ischemic Heart Disease: Results of an Open-Label, Multicenter Trial. J Womens Health (Larchmt) 2019; 28:573-582. [PMID: 30888919 PMCID: PMC6537111 DOI: 10.1089/jwh.2018.7019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Persistent angina is prevalent in women, who more often present with atypical angina, and experience less relief from antianginal therapies. The impact of ranolazine on female-specific angina is unclear. A single-arm, open-label trial was conducted to quantify the impact of ranolazine on angina in women with ischemic heart disease (IHD). Materials and Methods: Women with IHD and ≥2 angina episodes/week were recruited from 30 U.S. sites. Angina and nitroglycerin (NTG) consumption were assessed using patient-reported diaries, Seattle Angina Questionnaire (SAQ), Duke Activity Score Index (DASI), and Women's Ischemia Symptom Questionnaire (WISQ) at baseline and at 4 weeks of treatment with ranolazine 500 mg twice/day. A modified intent-to-treat analysis and parametric or nonparametric methods were used as appropriate to analyze changes. Results: Of 171 women enrolled, mean age was 65 ± 12 years. Of the 159 women included in the analysis, at week 4 compared to baseline, median angina frequency decreased with ranolazine treatment from 5.0 to 1.5 attacks/week and median change from baseline was -3.3 (95% confidence interval [CI]: -4.0 to -2.5; p ≤ 0.0001). Median NTG consumption decreased from 2.0 to 0.0 per week over the 4 weeks and median change was -1.0 (95% CI: -2.0 to -0.5; p < 0.0001). All five SAQ subscales showed mean improvements: physical limitation 9.2 (standard error [SE] 1.5; p < 0.0001), angina stability 31.8 (SE 2.7; p < 0.0001), angina frequency 17.7 (SE 1.6; p < 0.0001), treatment satisfaction 9.3 (SE 1.6; p < 0.0001), and disease perception 2.9 (SE 0.8; p < 0.0001). DASI score also improved 2.9 (SE 0.8; p = 0.0014). WISQ subscales also showed significant improvements (all p < 0.0001). Thirty-one women reported drug-related adverse events (AEs), predominantly mild to moderate gastrointestinal symptoms. Conclusions: Women with IHD treated with ranolazine for 4 weeks experienced less angina measured by SAQ and WISQ. NTG use decreased, physical activity improved, and treatment satisfaction improved. AEs were consistent with prior reports.
Collapse
Affiliation(s)
- Puja K. Mehta
- Division of Cardiology and Emory Women's Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Shilpa Sharma
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Margo Minissian
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | | | - John A. Nyman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Leslee J. Shaw
- Department of Radiology, Weil Cornell Medicine, New York, New York
| | - C. Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Nanette K. Wenger
- Division of Cardiology and Emory Women's Heart Center, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
4
|
Nelson MD. Left ventricular diastolic dysfunction in women with nonobstructive ischemic heart disease: insights from magnetic resonance imaging and spectroscopy. Am J Physiol Regul Integr Comp Physiol 2017; 313:R322-R329. [PMID: 28794105 DOI: 10.1152/ajpregu.00249.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/20/2017] [Accepted: 08/03/2017] [Indexed: 02/01/2023]
Abstract
Ischemic heart disease, in the absence of obstructive coronary artery disease, is prevalent in women and constitutes a major risk factor for developing major adverse cardiovascular events, including myocardial infarction, stroke, and heart failure. For decades, diagnosis was considered benign and often minimized; however, it is now known that this etiology carries much risk and is a significant burden to the health care system. This review summarizes the current state of knowledge on nonobstructive ischemic heart disease (NOIHD), the association between NOIHD and left ventricular diastolic dysfunction, potential links between NOIHD and the development of heart failure with preserved ejection fraction (HFpEF), and therapeutic options and knowledge gaps for patients living with NOIHD.
Collapse
Affiliation(s)
- Michael D Nelson
- Applied Physiology and Advanced Imaging Laboratory, University of Texas at Arlington, Arlington, Texas
| |
Collapse
|
5
|
Salazar CA, Basilio Flores JE, Veramendi Espinoza LE, Mejia Dolores JW, Rey Rodriguez DE, Loza Munárriz C. Ranolazine for stable angina pectoris. Cochrane Database Syst Rev 2017; 2:CD011747. [PMID: 28178363 PMCID: PMC6373632 DOI: 10.1002/14651858.cd011747.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Stable angina pectoris is a chronic medical condition with significant impact on mortality and quality of life; it can be macrovascular or microvascular in origin. Ranolazine is a second-line anti-anginal drug approved for use in people with stable angina. However, the effects of ranolazine for people with angina are considered to be modest, with uncertain clinical relevance. OBJECTIVES To assess the effects of ranolazine on cardiovascular and non-cardiovascular mortality, all-cause mortality, quality of life, acute myocardial infarction incidence, angina episodes frequency and adverse events incidence in stable angina patients, used either as monotherapy or as add-on therapy, and compared to placebo or any other anti-anginal agent. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and the Conference Proceedings Citation Index - Science in February 2016, as well as regional databases and trials registers. We also screened reference lists. SELECTION CRITERIA Randomised controlled trials (RCTs) which directly compared the effects of ranolazine versus placebo or other anti-anginals in people with stable angina pectoris were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed risk of bias. Estimates of treatment effects were calculated using risk ratios (RR), mean differences (MD) and standardised mean differences (SMD) with 95% confidence intervals (CI) using a fixed-effect model. Where we found statistically significant heterogeneity (Chi² P < 0.10), we used a random-effects model for pooling estimates. Meta-analysis was not performed where we found considerable heterogeneity (I² ≥ 75%). We used GRADE criteria to assess evidence quality and the GRADE profiler (GRADEpro GDT) to import data from Review Manager 5.3 to create 'Summary of findings' tables. MAIN RESULTS We included 17 RCTs (9975 participants, mean age 63.3 years). We found very limited (or no) data to inform most planned comparisons. Summary data were used to inform comparison of ranolazine versus placebo. Overall, risk of bias was assessed as unclear.For add-on ranolazine compared to placebo, no data were available to estimate cardiovascular and non-cardiovascular mortality. We found uncertainty about the effect of ranolazine on: all-cause mortality (1000 mg twice daily, RR 0.83, 95% CI 0.26 to 2.71; 3 studies, 2053 participants; low quality evidence); quality of life (any dose, SMD 0.25, 95% CI -0.01 to 0.52; 4 studies, 1563 participants; I² = 73%; moderate quality evidence); and incidence of non-fatal acute myocardial infarction (AMI) (1000mg twice daily, RR 0.40, 95% CI 0.08 to 2.07; 2 studies, 1509 participants; low quality evidence). Add-on ranolazine 1000 mg twice daily reduced the fervour of angina episodes (MD -0.66, 95% CI -0.97 to -0.35; 3 studies, 2004 participants; I² = 39%; moderate quality evidence) but increased the risk of non-serious adverse events (RR 1.22, 95% CI 1.06 to 1.40; 3 studies, 2053 participants; moderate quality evidence).For ranolazine as monotherapy compared to placebo, we found uncertain effect on cardiovascular mortality (1000 mg twice daily, RR 1.03, 95% CI 0.56 to 1.88; 1 study, 2604 participants; low quality evidence). No data were available to estimate non-cardiovascular mortality. We also found an uncertain effect on all-cause mortality for ranolazine (1000 mg twice daily, RR 1.00, 95% CI 0.81 to 1.25; 3 studies, 6249 participants; low quality evidence), quality of life (1000 mg twice daily, MD 0.28, 95% CI -1.57 to 2.13; 3 studies, 2254 participants; moderate quality evidence), non-fatal AMI incidence (any dose, RR 0.88, 95% CI 0.69 to 1.12; 3 studies, 2983 participants; I² = 50%; low quality evidence), and frequency of angina episodes (any dose, MD 0.08, 95% CI -0.85 to 1.01; 2 studies, 402 participants; low quality evidence). We found an increased risk for non-serious adverse events associated with ranolazine (any dose, RR 1.50, 95% CI 1.12 to 2.00; 3 studies, 947 participants; very low quality evidence). AUTHORS' CONCLUSIONS We found very low quality evidence showing that people with stable angina who received ranolazine as monotherapy had increased risk of presenting non-serious adverse events compared to those given placebo. We found low quality evidence indicating that people with stable angina who received ranolazine showed uncertain effect on the risk of cardiovascular death (for ranolazine given as monotherapy), all-cause death and non-fatal AMI, and the frequency of angina episodes (for ranolazine given as monotherapy) compared to those given placebo. Moderate quality evidence indicated that people with stable angina who received ranolazine showed uncertain effect on quality of life compared with people who received placebo. Moderate quality evidence also indicated that people with stable angina who received ranolazine as add-on therapy had fewer angina episodes but increased risk of presenting non-serious adverse events compared to those given placebo.
Collapse
Affiliation(s)
- Carlos A Salazar
- Universidad Peruana Cayetano HerediaDepartment of MedicineAvenida Honorio Delgado 430San Martin de PorresLimaLimaPeru
| | | | | | - Jhon W Mejia Dolores
- Universidad Nacional Mayor de San MarcosFaculty of MedicineAv. Grau 755LimaLimaPeru
| | | | - César Loza Munárriz
- Universidad Peruana Cayetano HerediaDepartment of NephrologyHospital Cayetano HerediaHonorio Delgado 420LimaPeru31
| | | |
Collapse
|
6
|
Nelson MD, Sharif B, Shaw JL, Cook-Wiens G, Wei J, Shufelt C, Mehta PK, Thomson LEJ, Berman DS, Thompson RB, Handberg EM, Pepine CJ, Li D, Bairey Merz CN. Myocardial tissue deformation is reduced in subjects with coronary microvascular dysfunction but not rescued by treatment with ranolazine. Clin Cardiol 2016; 40:300-306. [PMID: 28004395 DOI: 10.1002/clc.22660] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/29/2016] [Accepted: 11/23/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with coronary microvascular dysfunction (CMD) often have diastolic dysfunction, representing an important therapeutic target. Ranolazine-a late sodium current inhibitor-improves diastolic function in animal models and subjects with obstructive coronary artery disease (CAD). HYPOTHESIS We hypothesized that ranolazine would beneficially alter diastolic function in CMD. METHODS To test this hypothesis, we performed retrospective tissue tracking analysis to evaluate systolic/diastolic strain, using cardiac magnetic resonance imaging cine images acquired in a recently completed, randomized, double-blind, placebo-controlled, crossover trial of short-term ranolazine in subjects with CMD and from 43 healthy reference controls. RESULTS Diastolic strain rate was impaired in CMD vs controls (circumferential diastolic strain rate: 99.9% ± 2.5%/s vs 120.1% ± 4.0%/s, P = 0.0003; radial diastolic strain rate: -199.5% ± 5.5%/s vs -243.1% ± 9.6%/s, P = 0.0008, case vs control). Moreover, peak systolic circumferential strain (CS) and radial strain (RS) were also impaired in cases vs controls (CS: -18.8% ± 0.3% vs -20.7% ± 0.3%; RS: 35.8% ± 0.7% vs 41.4% ± 0.9%; respectively; both P < 0.0001), despite similar and preserved ejection fraction. In contrast to our hypothesis, however, we observed no significant changes in left ventricular diastolic function in CMD cases after 2 weeks of ranolazine vs placebo. CONCLUSIONS The case-control comparison both confirms and extends our prior observations of diastolic dysfunction in CMD. That CMD cases were also found to have subclinical systolic dysfunction is a novel finding, highlighting the utility of this retrospective approach. In contrast to previous studies in obstructive CAD, ranolazine did not improve diastolic function in CMD.
Collapse
Affiliation(s)
- Michael D Nelson
- Applied Physiology and Advanced Imaging Laboratory, University of Texas at Arlington, Arlington, Texas.,Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California.,Barbra Streisand Women's Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Behzad Sharif
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jaime L Shaw
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galen Cook-Wiens
- Biostatistics Core, Cedars-Sinai Medical Center, Los Angeles, California
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.,Emory Women's Heart Center, Emory University School of Medicine, Atlanta, Georgia
| | - Louise E J Thomson
- Mark S. Taper Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel S Berman
- Emory Women's Heart Center, Emory University School of Medicine, Atlanta, Georgia.,Mark S. Taper Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Eileen M Handberg
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Carl J Pepine
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Debiao Li
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - C Noel Bairey Merz
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
7
|
Manolis AJ, Poulimenos LE, Ambrosio G, Kallistratos MS, Lopez-Sendon J, Dechend R, Mancia G, Camm AJ. Medical treatment of stable angina: A tailored therapeutic approach. Int J Cardiol 2016; 220:445-53. [DOI: 10.1016/j.ijcard.2016.06.150] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/18/2016] [Accepted: 06/24/2016] [Indexed: 01/17/2023]
|
8
|
Bairey Merz CN, Handberg EM, Shufelt CL, Mehta PK, Minissian MB, Wei J, Thomson LEJ, Berman DS, Shaw LJ, Petersen JW, Brown GH, Anderson RD, Shuster JJ, Cook-Wiens G, Rogatko A, Pepine CJ. A randomized, placebo-controlled trial of late Na current inhibition (ranolazine) in coronary microvascular dysfunction (CMD): impact on angina and myocardial perfusion reserve. Eur Heart J 2015; 37:1504-13. [PMID: 26614823 PMCID: PMC4872284 DOI: 10.1093/eurheartj/ehv647] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 11/09/2015] [Indexed: 01/04/2023] Open
Abstract
Aims The mechanistic basis of the symptoms and signs of myocardial ischaemia in patients without obstructive coronary artery disease (CAD) and evidence of coronary microvascular dysfunction (CMD) is unclear. The aim of this study was to mechanistically test short-term late sodium current inhibition (ranolazine) in such subjects on angina, myocardial perfusion reserve index, and diastolic filling. Materials and results Randomized, double-blind, placebo-controlled, crossover, mechanistic trial in subjects with evidence of CMD [invasive coronary reactivity testing or non-invasive cardiac magnetic resonance imaging myocardial perfusion reserve index (MPRI)]. Short-term oral ranolazine 500–1000 mg twice daily for 2 weeks vs. placebo. Angina measured by Seattle Angina Questionnaire (SAQ) and SAQ-7 (co-primaries), diary angina (secondary), stress MPRI, diastolic filling, quality of life (QoL). Of 128 (96% women) subjects, no treatment differences in the outcomes were observed. Peak heart rate was lower during pharmacological stress during ranolazine (−3.55 b.p.m., P < 0.001). The change in SAQ-7 directly correlated with the change in MPRI (correlation 0.25, P = 0.005). The change in MPRI predicted the change in SAQ QoL, adjusted for body mass index (BMI), prior myocardial infarction, and site (P = 0.0032). Low coronary flow reserve (CFR <2.5) subjects improved MPRI (P < 0.0137), SAQ angina frequency (P = 0.027), and SAQ-7 (P = 0.041). Conclusions In this mechanistic trial among symptomatic subjects, no obstructive CAD, short-term late sodium current inhibition was not generally effective for SAQ angina. Angina and myocardial perfusion reserve changes were related, supporting the notion that strategies to improve ischaemia should be tested in these subjects. Trial registration clinicaltrials.gov Identifier: NCT01342029.
Collapse
Affiliation(s)
- C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | - Chrisandra L Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Margo B Minissian
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Louise E J Thomson
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Leslee J Shaw
- Program in Cardiovascular Outcomes Research and Epidemiology, Emory University, Atlanta, GA, USA
| | - John W Petersen
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Garrett H Brown
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - R David Anderson
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Jonathan J Shuster
- Health Outcomes and Policy, University of Florida Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA
| | - Galen Cook-Wiens
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - André Rogatko
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Carl J Pepine
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| |
Collapse
|
9
|
|
10
|
Dean J, Cruz SD, Mehta PK, Merz CNB. Coronary microvascular dysfunction: sex-specific risk, diagnosis, and therapy. Nat Rev Cardiol 2015; 12:406-14. [PMID: 26011377 DOI: 10.1038/nrcardio.2015.72] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease is the leading cause of death worldwide. In the presence of signs and symptoms of myocardial ischaemia, women are more likely than men to have no obstructive coronary artery disease (CAD). Women have a greater burden of symptoms than men, and are often falsely reassured despite the presence of ischaemic heart disease because of a lack of obstructive CAD. Coronary microvascular dysfunction should be considered as an aetiology for ischaemic heart disease with signs and symptoms of myocardial ischaemia, but no obstructive CAD. Coronary microvascular dysfunction is defined as impaired coronary flow reserve owing to functional and/or structural abnormalities of the microcirculation, and is associated with an adverse cardiovascular prognosis. Therapeutic lifestyle changes as well as antiatherosclerotic and antianginal medications might be beneficial, but clinical outcome trials are needed to guide treatment. In this Review, we discuss the prevalence, presentation, diagnosis, and treatment of coronary microvascular dysfunction, with a particular emphasis on ischaemic heart disease in women.
Collapse
Affiliation(s)
- Jenna Dean
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Sherwin Dela Cruz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - Puja K Mehta
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A3600, Los Angeles, CA 90048, USA
| |
Collapse
|
11
|
Cattaneo M, Porretta AP, Gallino A. Ranolazine: Drug overview and possible role in primary microvascular angina management. Int J Cardiol 2014; 181:376-81. [PMID: 25555283 DOI: 10.1016/j.ijcard.2014.12.055] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/21/2014] [Indexed: 12/19/2022]
Abstract
Ranolazine is a novel well-tolerated anti-ischemic drug, which selectively inhibits late sodium current and exerts metabolic properties without any hemodynamic effect. Ranolazine has been approved as a second-line medical treatment for symptomatic stable coronary artery disease. Primary microvascular angina (MVA) is suspected when angina symptoms occur in patients with demonstrated myocardial ischemia, absence of myocardial disease and normal coronary artery angiography. Recent clinical data suggest that MVA represents a complex entity, which has been increasingly recognized as a significant cause of morbidity. High variability and low response to traditional anti-anginal treatment characterize primary MVA. Despite the fact that clinical and preclinical evidence provides information regarding ranolazine usefulness in primary MVA management, only three recent small randomized trials have investigated this issue. By selecting peer-reviewed literature in Pubmed and Cochrane Library, this review provides an overview on ranolazine pharmacology and efficacy, focusing on recent evidence suggesting its usefulness in management of primary MVA.
Collapse
Affiliation(s)
- Mattia Cattaneo
- Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli-San Giovanni, Bellinzona, Switzerland.
| | - Alessandra Pia Porretta
- Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli-San Giovanni, Bellinzona, Switzerland
| | - Augusto Gallino
- Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli-San Giovanni, Bellinzona, Switzerland; University of Zürich, Zürich, Switzerland
| |
Collapse
|
12
|
Abstract
Mortality rates attributable to coronary heart disease have declined in recent years, possibly related to changes in clinical presentation patterns and use of proven secondary prevention strategies. Chronic stable angina (CSA) remains prevalent, and the goal of treatment is control of symptoms and reduction in cardiovascular events. Ranolazine is a selective inhibitor of the late sodium current in myocytes with anti-ischemic and metabolic properties. It was approved by the US Food and Drug Administration in 2006 for use in patients with CSA. Multiple, randomized, placebo-controlled trials have shown that ranolazine improves functional capacity and decreases anginal episodes in CSA patients, despite a lack of a significant hemodynamic effect. Ranolazine did not improve cardiovascular mortality or affect incidence of myocardial infarction in the MERLIN (Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndrome)-TIMI (Thrombolysis In Myocardial Infarction) 36 trial, but significantly decreased the incidence of recurrent angina. More recently, ranolazine has been shown to have beneficial and potent antiarrhythmic effects, both on supraventricular and ventricular tachyarrhythmias, largely due to its inhibition of the late sodium current. Randomized controlled trials testing these effects are underway. Lastly, ranolazine appears to be cost-effective due to its ability to decrease angina-related hospitalizations and improve quality of life.
Collapse
Affiliation(s)
- J Nicolás Codolosa
- Einstein Center for Heart and Vascular Health, Einstein Medical Center, Philadelphia, PA, USA
| | - Subroto Acharjee
- Einstein Center for Heart and Vascular Health, Einstein Medical Center, Philadelphia, PA, USA
| | - Vincent M Figueredo
- Einstein Center for Heart and Vascular Health, Einstein Medical Center, Philadelphia, PA, USA
- Jefferson Medical College, Philadelphia, PA, USA
| |
Collapse
|
13
|
Reffelmann T, Kloner RA. Ranolazine: an anti-anginal drug with further therapeutic potential. Expert Rev Cardiovasc Ther 2014; 8:319-29. [DOI: 10.1586/erc.09.178] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
14
|
A rare neurological complication of ranolazine. Case Rep Neurol Med 2013; 2013:451206. [PMID: 23936696 PMCID: PMC3713362 DOI: 10.1155/2013/451206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 06/19/2013] [Indexed: 12/19/2022] Open
Abstract
Myoclonus is not a known side effect of ranolazine. We report a case of myoclonus in a 72-year-old female who underwent cardiac catheterization for angina and was started on ranolazine after the procedure. Two days after ranolazine therapy on 1000 mg per day in divided doses, myoclonus developed, which severely impaired her normal activity. Her symptoms resolved 2 days after discontinuation of ranolazine. Ranolazine was resumed after discharge from hospital with recurrent myoclonus after two days of therapy. The causal relationship between ranolazine and myoclonus was suggested by cessation of myoclonus after ranolazine was discontinued.
Collapse
|
15
|
Abstract
Ranolazine is currently approved for use in chronic angina. The basis for this use is likely related to inhibition of late sodium channels with resultant beneficial downstream effects. Randomized clinical trials have demonstrated an improvement in exercise capacity and reduction in angina episodes with ranolazine. This therapeutic benefit occurs without the hemodynamic effects seen with the conventional antianginal agents. The inhibition of late sodium channels as well as other ion currents has a central role in the potential use of ranolazine in ischemic heart disease, arrhythmias, and heart failure. Despite its QTc-prolonging action, albeit minimal, clinical data have not shown a predisposition to torsades de pointes, and the medication has shown a reasonable safety profile even in those with structural heart disease. In this article we present the experimental and clinical data that support its current therapeutic role, and provide insight into potential future clinical applications.
Collapse
Affiliation(s)
- Nael Hawwa
- Internal Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | | |
Collapse
|
16
|
Zuchi C, Tritto I, Ambrosio G. Angina pectoris in women: Focus on microvascular disease. Int J Cardiol 2013; 163:132-40. [DOI: 10.1016/j.ijcard.2012.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 07/07/2012] [Accepted: 07/07/2012] [Indexed: 12/19/2022]
|
17
|
|
18
|
Cocco G. Management of myocardial ischemia. Is ranolazine needed? For all or some patients with myocardial ischemia? Expert Opin Pharmacother 2012; 13:2429-32. [PMID: 23121536 DOI: 10.1517/14656566.2012.741592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This editorial refers to 'Should ranolazine be used for all patients with ischemic heart disease or only for symptomatic patients with stable angina or for those with refractory angina pectoris? A critical appraisal' by U Thadani also published in this issue.
Collapse
|
19
|
Mehta PK, Goykhman P, Thomson LEJ, Shufelt C, Wei J, Yang Y, Gill E, Minissian M, Shaw LJ, Slomka PJ, Slivka M, Berman DS, Bairey Merz CN. Ranolazine improves angina in women with evidence of myocardial ischemia but no obstructive coronary artery disease. JACC Cardiovasc Imaging 2011; 4:514-22. [PMID: 21565740 PMCID: PMC6364688 DOI: 10.1016/j.jcmg.2011.03.007] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 03/02/2011] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We conducted a pilot study for a large definitive clinical trial evaluating the impact of ranolazine in women with angina, evidence of myocardial ischemia, and no obstructive coronary artery disease (CAD). BACKGROUND Women with angina, evidence of myocardial ischemia, but no obstructive CAD frequently have microvascular coronary dysfunction. The impact of ranolazine in this patient group is unknown. METHODS A pilot randomized, double-blind, placebo-controlled, crossover trial was conducted in 20 women with angina, no obstructive CAD, and ≥ 10% ischemic myocardium on adenosine stress cardiac magnetic resonance (CMR) imaging. Participants were assigned to ranolazine or placebo for 4 weeks separated by a 2-week washout. The Seattle Angina Questionnaire and CMR were evaluated after each treatment. Invasive coronary flow reserve (CFR) was available in patients who underwent clinically indicated coronary reactivity testing. CMR data analysis included the percentage of ischemic myocardium and quantitative myocardial perfusion reserve index (MPRI). RESULTS The mean age of subjects was 57 ± 11 years. Compared with placebo, patients on ranolazine had significantly higher (better) Seattle Angina Questionnaire scores, including physical functioning (p = 0.046), angina stability (p = 0.008), and quality of life (p = 0.021). There was a trend toward a higher (better) CMR mid-ventricular MPRI (2.4 [2.0 minimum, 2.8 maximum] vs. 2.1 [1.7 minimum, 2.5 maximum], p = 0.074) on ranolazine. Among women with coronary reactivity testing (n = 13), those with CFR ≤ 3.0 had a significantly improved MPRI on ranolazine versus placebo compared to women with CFR > 3.0 (Δ in MPRI 0.48 vs. -0.82, p = 0.04). CONCLUSIONS In women with angina, evidence of ischemia, and no obstructive CAD, this pilot randomized, controlled trial revealed that ranolazine improves angina. Myocardial ischemia may also improve, particularly among women with low CFR. These data document approach feasibility and provide outcome variability estimates for planning a definitive large clinical trial to evaluate the role of ranolazine in women with microvascular coronary dysfunction. (Microvascular Coronary Disease In Women: Impact Of Ranolazine; NCT00570089).
Collapse
Affiliation(s)
- Puja K. Mehta
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Pavel Goykhman
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Louise E. J. Thomson
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chrisandra Shufelt
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Janet Wei
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - YuChing Yang
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Edward Gill
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Margo Minissian
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Leslee J. Shaw
- Program in Cardiovascular Outcomes Research and Epidemiology, Emory University, Atlanta, Georgia
| | - Piotr J. Slomka
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Melissa Slivka
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Daniel S. Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | | |
Collapse
|
20
|
Abstract
Chronic stable angina is an exceedingly prevalent condition with tremendous clinical, social, and financial implications. Traditional medical therapy for angina consists of beta-blockers, calcium channel blockers, and nitrates. These agents decrease myocardial oxygen demand and ischemia by reducing heart rate, lowering blood pressure, and/or optimizing ventricular loading characteristics. Unique in its mechanism of action, ranolazine is the first new antianginal agent approved for use in the US for chronic angina in over 25 years. By inhibiting the late inward sodium current (I(Na)), ranolazine prevents pathologic intracellular calcium accumulation that leads to ischemia, myocardial dysfunction, and electrical instability. Ranolazine has been proven in multiple clinical trials to reduce the symptoms of angina safely and effectively and to improve exercise tolerance in patients with symptomatic coronary heart disease. These benefits occur without reduction in heart rate and blood pressure or increased mortality. Although ranolazine prolongs the QT(c), experimental data indicate that ranolazine may actually be antiarrhythmic. In a large acute coronary syndrome clinical trial, ranolazine reduced the incidence of supraventricular tachycardia, ventricular tachycardia, new-onset atrial fibrillation, and bradycardic events. Additional benefits of ranolazine under investigation include reductions in glycosylated hemoglobin levels and improved left ventricular function. Ranolazine is a proven antianginal medication in patients with symptomatic coronary heart disease, and should be considered as an initial antianginal agent for those with hypotension or bradycardia.
Collapse
Affiliation(s)
- David S Vadnais
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | |
Collapse
|
21
|
Singh JP, Rosenthal LS, Hranitzky PM, Berg KC, Mullin CM, Thackeray L, Kaplan A. Device diagnostics and long-term clinical outcome in patients receiving cardiac resynchronization therapy. Europace 2009; 11:1647-53. [PMID: 19752011 DOI: 10.1093/europace/eup250] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS This retrospective analysis sought to develop and validate a model using the measured diagnostic variables in cardiac resynchronization therapy (CRT) devices to predict mortality. METHODS AND RESULTS Data used in this analysis came from two CRT studies: Cardiac Resynchronization Therapy Registry Evaluating Patient Response with RENEWAL Family Devices (CRT RENEWAL) (n = 436) and Heart Failure-Heart Rate Variability (HF-HRV) (n = 838). Patients from CRT RENEWAL were used to create a model for risk of death using logistic regression and to create a scoring system that could be used to predict mortality. Results of both the logistic regression and the clinical risk score were validated in a cohort of patients from the HF-HRV study. Diagnostics significantly improved over time post-CRT implant (all P < 0.001) and were correlated with a trend of decreased risk of death. The regression model classified CRT RENEWAL patients into low (2.8%), moderate (6.9%), and high (13.8%) risk of death based on tertiles of their model predicted risk. The clinical risk score classified CRT RENEWAL patients into low (2.8%), moderate (10.1%), and high (13.4%) risk of death based on tertiles of their score. When both the regression model and the clinical risk score were applied to the HF-HRV study, each was able to classify patients into appropriate levels of risk. CONCLUSION Device diagnostics may be used to create models that predict the risk of death.
Collapse
Affiliation(s)
- Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA.
| | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Chronic stable angina is a debilitating illness affecting at least 6.6 million US residents. Despite being optimally treated by pharmacotherapy and revascularization up to 26% of patients still experience angina. Diabetes mellitus is a common co-morbid condition in angina patients. Several new investigational medications are being tested for chronic angina. Advances in understanding of myocardial ischemia have prompted evaluation of a number of new antianginal strategies. In this review we discuss the utility of ranolazine, a recently approved novel antianginal agent and its efficacy in the diabetic patient population. In addition to its antianginal action in diabetic patients with chronic angina, ranolazine may have favorable effects on glycated hemoglobin levels.
Collapse
Affiliation(s)
- Pawan D Patel
- Department of Cardiology, Chicago Medical School, North Chicago, IL 60064, USA
| | | |
Collapse
|
23
|
Abstract
Ranolazine is a new and unique antianginal drug that has been approved for the treatment of chronic stable angina pectoris. The drug is administered as a sustained-release formulation. Although the drug's mechanism of action has not been fully elucidated, current thinking is that ranolazine, a selective inhibitor of late sodium influx, attenuates the abnormalities of ventricular repolarisation and contractility associated with ischaemia. Three randomised trials have shown efficacy for ranolazine in increasing exercise testing or reducing anginal episodes or use of glyceryl trinitrate. Side-effects include dizziness, constipation, nausea, and the potential for prolongation of the QT(c) interval. Ranolazine seems to be a safe addition to current traditional drugs for chronic stable angina, especially in aggressive multidrug regimens.
Collapse
Affiliation(s)
- David T Nash
- Syracuse Preventive Cardiology, Syracuse, NY 13202, USA.
| | | |
Collapse
|
24
|
|