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Lantz R, Quesada O, Mattingly G, Henry TD. Contemporary Management of Refractory Angina. Interv Cardiol Clin 2022; 11:279-292. [PMID: 35710283 PMCID: PMC9275781 DOI: 10.1016/j.iccl.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Refractory angina (RA) is defined as chest pain caused by coronary ischemia in patients on maximal medical therapy and is not amenable to revascularization despite advanced coronary artery disease (CAD). The long-term prognosis has improved with optimal medical therapy including risk factor modification. Still, patients are left with major impairment in quality of life and have high resource utilization with limited treatment options. We review the novel invasive and noninvasive therapies under investigation for RA.
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Affiliation(s)
- Rebekah Lantz
- The Lindner Research Center at the Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA
| | - Odayme Quesada
- Women's Heart Program at The Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA. https://twitter.com/Odayme
| | - Georgia Mattingly
- The Lindner Research Center at the Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA.
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Povsic TJ, Henry TD, Ohman EM, Pepine CJ, Crystal RG, Rosengart TK, Reinhardt RR, Dittrich HC, Traverse JH, Answini GA, Mokadam NA. Epicardial delivery of XC001 gene therapy for refractory angina coronary treatment (The EXACT Trial): Rationale, design, and clinical considerations. Am Heart J 2021; 241:38-49. [PMID: 34224684 DOI: 10.1016/j.ahj.2021.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/25/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients with refractory angina (RA) have poor quality of life and new therapies are needed. XC001 is a novel adenoviral vector expressing multiple isoforms of vascular endothelial growth factor (VEGF) promoting an enhanced local angiogenic effect. METHODS The Epicardial Delivery of XC001 Gene Therapy for Refractory Angina Coronary Treatment (EXACT) trial is a 6-month (with 6-month extension) phase 1/2, first-in-human, multicenter, open-label, single-arm, dose-escalation study to evaluate the safety, tolerability, and preliminary efficacy of XC001 in patients with RA. The trial will enroll 33 patients in an initial (n = 12) ascending dose-escalation phase (1 × 109, 1 × 1010, 4 × 1010, and 1 × 1011 viral particles), followed by phase 2 (n = 21) assessing the highest tolerated dose. Patients must have stable Canadian Cardiovascular Society (CCS) class II-IV angina on maximally tolerated medical therapy without options for conventional revascularization, demonstrable ischemia on stress testing, and angina limiting exercise tolerance. XC001 will be delivered directly to ischemic myocardium via surgical transthoracic epicardial access. The primary outcome is safety via adverse event monitoring through 6 months. Efficacy assessments include difference from baseline to month 6 in time to 1 mm of ST segment depression, time to angina, and total exercise duration; myocardial blood flow at rest, and stress and coronary flow reserve by positron emission tomography; quality of life; CCS functional class; and angina frequency. CONCLUSIONS The EXACT trial will determine whether direct intramyocardial administration of XC001 in patients with RA is safe and evaluate its effect on exercise tolerance, myocardial perfusion, angina and physical activity, informing future clinical investigation. CLINICAL TRIAL REGISTRATION NCT04125732.
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Affiliation(s)
- Thomas J Povsic
- Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC.
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
| | - E Magnus Ohman
- Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Ronald G Crystal
- Department of Genetic Medicine, Weill Cornell Medicine, New York, NY
| | | | | | | | - Jay H Traverse
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN
| | - Geoffrey A Answini
- Division of Cardiovascular Surgery, The Christ Hospital Physicians-Heart & Vascular, Cincinnati, OH
| | - Nahush A Mokadam
- Division of Cardiac Surgery, The Ohio State Wexner Medical Center, Columbus, OH
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Bassetti B, Rurali E, Gambini E, Pompilio G. Son of a Lesser God: The Case of Cell Therapy for Refractory Angina. Front Cardiovasc Med 2021; 8:709795. [PMID: 34552966 PMCID: PMC8450394 DOI: 10.3389/fcvm.2021.709795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/02/2021] [Indexed: 11/20/2022] Open
Abstract
In the last decades, various non-pharmacological solutions have been tested on top of medical therapy for the treatment of patients affected by refractory angina (RA). Among these therapeutics, neuromodulation, external counter-pulsation and coronary sinus constriction have been recently introduced in the guidelines for the management of RA in United States and Europe. Notably and paradoxically, although a consistent body of evidence has proposed cell-based therapies (CT) as safe and salutary for RA outcome, CT has not been conversely incorporated into current international guidelines yet. As a matter of fact, published randomized controlled trials (RCT) and meta-analyses (MTA) cumulatively indicated that CT can effectively increase perfusion, physical function and well-being, thus reducing angina symptoms and drug assumption in RA patients. In this review, we (i) provide an updated overview of novel non-pharmacological therapeutics included in current guidelines for the management of patients with RA, (ii) discuss the Level of Evidence stemmed from available clinical trials for each recommended treatment, and (iii) focus on evidence-based CT application for the management of RA.
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Affiliation(s)
- Beatrice Bassetti
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Erica Rurali
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Elisa Gambini
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Oloker Therapeutics S.r.l., Bari, Italy
| | - Giulio Pompilio
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Milan, Italy
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Verheye S, Agostoni P, Giannini F, Hill JM, Jensen C, Lindsay S, Stella P, Redwood SR, Banai S, Konigstein M. Coronary sinus narrowing for the treatment of refractory angina: a multicentre prospective open-label clinical study (the REDUCER-I study). EUROINTERVENTION 2021; 17:561-568. [PMID: 33319762 PMCID: PMC9724967 DOI: 10.4244/eij-d-20-00873] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The REDUCER-I study is a prospective (with a retrospective component), open-label, multi-centre, international, post-market study, which collects long-term data of patients with refractory angina treated with the Reducer. Here we present the overall clinical outcomes of the first 228 patients enrolled. AIMS The aim of this study is to examine the safety and efficacy of the coronary sinus (CS) Reducer in improving angina severity and quality of life in patients suffering from angina pectoris, refractory to medical and interventional therapies. METHODS REDUCER-I is a multicentre, non-randomised observational study. Enrolled patients had refractory angina pectoris Canadian Cardiovascular Society (CCS) class II-IV and were treated with Reducer implantation. RESULTS In the first 228 patients (81% male, 68.3±9.6 years), the procedural success rate was 99%, with only one adjudicated possible procedural or device-related MACE. Mean CCS class decreased from 2.8±0.6 at baseline, to 1.8±0.7 at two years. Improvement in ≥1 CCS class was observed in 82%, and in ≥2 CCS classes in 31% of patients at two years. At baseline, 70% of the cohort were reported to be in CCS class III-IV; this portion was reduced to 15% at follow-up. Additional measured parameters of functional class and quality of life were also improved. CONCLUSIONS Interim results from the ongoing REDUCER-I study confirm the high safety profile of this therapy in patients suffering from refractory angina. The results also demonstrate sustained improvement in angina severity and in quality of life up to two years.
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Affiliation(s)
- Stefan Verheye
- Cardiovascular Center, ZNA Middelheim Hospital, Lindendreef Antwerp, Belgium
| | | | | | | | | | - Steven Lindsay
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | | | - Simon R. Redwood
- St Thomas’ Hospital Cardiothoracic Centre, London, United Kingdom
| | - Shmuel Banai
- Tel Aviv Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maayan Konigstein
- Department of Cardiology, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906, Israel
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Matta A, Nader V, Galinier M, Roncalli J. Transplantation of CD34+ cells for myocardial ischemia. World J Transplant 2021; 11:138-146. [PMID: 34046316 PMCID: PMC8131931 DOI: 10.5500/wjt.v11.i5.138] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/01/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
CD34+ cells are multipotent hematopoietic stem cells also known as endothelial progenitor cells and are useful in regenerative medicine. Naturally, these cells are mobilized from the bone marrow into peripheral circulation in response to ischemic tissue injury. CD34+ cells are known for their high proliferative and differentiation capacities that play a crucial role in the repair process of myocardial damage. They have an important paracrine activity in secreting factors to stimulate vasculogenesis, reduce endothelial cells and cardiomyocytes apoptosis, remodel extracellular matrix and activate additional progenitor cells. Once they migrate to the target site, they enhance angiogenesis, neovascularization and tissue regeneration. Several trials have demonstrated the safety and efficacy of CD34+ cell therapy in different settings, such as peripheral limb ischemia, stroke and cardiovascular disease. Herein, we review the potential utility of CD34+ cell transplantation in acute myocardial infarction, refractory angina and ischemic heart failure.
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Affiliation(s)
- Anthony Matta
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse 31059, France
- Faculty of Medicine, Holy Spirit University of Kaslik, Kaslik 00000, Lebanon
| | - Vanessa Nader
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse 31059, France
- Faculty of Pharmacy, Lebanese University, Beirut 961, Lebanon
| | - Michel Galinier
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse 31059, France
| | - Jerome Roncalli
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse 31059, France
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Abstract
The combination of an aging population and improved survival rates among patients with coronary artery disease has resulted in an increase in the number of patients with refractory angina or anginal equivalent symptoms despite maximal medical therapy. Patients with refractory angina are often referred to the cardiac catheterization laboratory; however, they have often exhausted conventional revascularization options; thus, this population is often deemed as having "no options." We review the definition, prevalence, outcomes, therapeutic options, and treatment considerations for no-option refractory angina patients and focus on novel therapies for this complex and challenging population. We propose a multidisciplinary team approach for the evaluation and management of patients with refractory angina, ideally in a designated clinic. The severe limitations and symptomatology experienced by these patients highlight the need for additional research into the development of innovative treatments.
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Affiliation(s)
- Thomas J Povsic
- Department of Medicine, Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (T.J.P., E.M.O.)
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | - E Magnus Ohman
- Department of Medicine, Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (T.J.P., E.M.O.)
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Jolicoeur EM, Henry TD. The cost of angina: how do we measure it? How do we improve it? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:5-6. [PMID: 31633770 DOI: 10.1093/ehjqcco/qcz058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Etienne Marc Jolicoeur
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Québec, Canada
| | - Timothy D Henry
- The Christ Hospital Heart and Vascular Center/The Lindner Center for Research and Education, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA
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Riley RF, Kereiakes DJ, Henry TD. Response by Riley et al to Letter Regarding Article, "More Data Than Options for the 'No-Option' Refractory Angina Patient in the United States". Circ Res 2019; 125:e42. [PMID: 31600126 DOI: 10.1161/circresaha.119.315845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robert F Riley
- The Christ Hospital Heart and Vascular Center/The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
| | - Dean J Kereiakes
- The Christ Hospital Heart and Vascular Center/The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
| | - Timothy D Henry
- The Christ Hospital Heart and Vascular Center/The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
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Riley RF, Kereiakes DJ, Henry TD. More Data Than Options for the “No-Option” Refractory Angina Patient in the United States. Circ Res 2019; 124:1689-1691. [DOI: 10.1161/circresaha.119.315138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robert F. Riley
- From the Christ Hospital Heart and Vascular Center / The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
| | - Dean J. Kereiakes
- From the Christ Hospital Heart and Vascular Center / The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
| | - Timothy D. Henry
- From the Christ Hospital Heart and Vascular Center / The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
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