The Importance of Pan-Immune Inflammation Value (PIV) in Predicting Coronary Collateral Circulation in Stable Coronary Artery Patients

In this study, the correlation between pan-immune-inflammation value (PIV) and coronary collateral circulation (CCC) in patients with chronic coronary syndrome (CCS) was analyzed. The study included 663 patients with CCS who underwent coronary angiography and had coronary stenosis of ≥95% in at least one major coronary vessel. The participants were divided into two groups: good CCC (Rentrop score 2-3) and poor CCC (Rentrop score 0-1). PIV score was calculated as monocyte x platelet x neutrophil/lymphocyte count. When the patient groups who developed good and poor CCC were compared, neutrophil/lymphocyte ratio (NLR) (P < .001), C-reactive protein (CRP) levels, CRP/albumin ratio (CAR) (P < .001), systemic immune-inflammation index (SII) (P < .001), and PIV (P < .001) were higher in patients with poor CCC. In multivariate logistic regression analysis, age, SII, NLR, CRP, CAR, and PIV were found to be independent predictors of poor CCC (P < .001, for all). Receiver operating characteristic (ROC) analysis demonstrated that a cut-off value of 442.2 for PIV predicted poor CCC slightly better compared to other markers, with 76.8% sensitivity and 70.1% specificity (area under ROC curve = 0.808 (95% CI: 0.764-0.851), P < .001). These findings suggest that PIV can be used as an independent predictor of CCC development.

Lesion-specific pericoronary adipose tissue CT attenuation improves risk prediction of major adverse cardiovascular events in coronary artery disease

OBJECTIVES

To determine whether lesion-specific pericoronary adipose tissue CT attenuation (PCATa) is superior to PCATa around the proximal right coronary artery (PCATa-RCA) and left anterior descending artery (PCATa-LAD) for major adverse cardiovascular events (MACE) prediction in coronary artery disease (CAD).

METHODS

Six hundred and eight CAD patients who underwent coronary CTA from January 2014 to December 2018 were retrospectively included, with clinical risk factors, plaque features, lesion-specific PCATa, PCATa-RCA, and PCATa-LAD collected. MACE was defined as cardiovascular death, non-fatal myocardial infarction, unplanned revascularization, and hospitalization for unstable angina. Four models were established, encapsulating traditional factors (Model A), traditional factors and PCATa-RCA (Model B), traditional factors and PCATa-LAD (Model C), and traditional factors and lesion-specific PCATa (Model D). Prognostic performance was evaluated with C-statistic, area under receiver operator characteristic curve (AUC), and net reclassification index (NRI).

RESULTS

Lesion-specific PCATa was an independent predictor for MACE (adjusted hazard ratio = 1.108, P < .001). The C-statistic increased from 0.750 for model A to 0.762 for model B (P = .078), 0.773 for model C (P = .046), and 0.791 for model D (P = .005). The AUC increased from 0.770 for model A to 0.793 for model B (P = .027), 0.793 for model C (P = .387), and 0.820 for model D (P = .019). Compared with model A, the NRIs for models B, C, and D were 0.243 (-0.323 to 0.792, P = .392), 0.428 (-0.012 to 0.835, P = .048), and 0.708 (0.152-1.016, P = .001), respectively.

CONCLUSIONS

Lesion-specific PCATa improves risk prediction of MACE in CAD, which is better than PCATa-RCA and PCATa-LAD.

ADVANCES IN KNOWLEDGE

Lesion-specific PCATa was superior to PCATa-RCA and PCATa-LAD for MACE prediction.

Are Thiols Useful Biomarkers for Coronary Collateral Circulation in Patients with Stable Coronary Artery Disease?

Our aim was to investigate the relationship between thiol, which is the main component of the antioxidant system, and coronary collateral circulation (CCC). Our patients consisted of people with stable coronary artery disease (sCAD) and total occlusion in at least one vessel (n = 249). We divided the patients into two groups, good and poor, according to their CCC degree. We determined that DM, total thiol, and disulfide are independent predictors of poor CCC in multivariate logistic regression analysis (OR: 1.012, 95% CI: 1.008-1.017, p < 0.001; OR: 1.022, 95% CI: 1.000-1.044, p = 0.044; OR: 2.671, 95% CI: 1.238-5.761, p = 0.012, respectively). The ROC analysis showed a cut-off value of 328.7 for native thiol regarding the prediction of poor CCC, with 67.4% specificity and 78% sensitivity. For disulfide, it revealed a cut-off value of 15.1 regarding the prediction of poor CCC, with 57.9% specificity and 69.5% sensitivity. In this study, we detected that the patients with sCAD who developed poor CCC had lower levels of native thiol, total thiol, and disulfide compared to those with good CCC. The most interesting finding of our study is that CCC formation is an effective predictor of the antioxidant cascade rather than the inflammation cascade in sCAD patients.

Comparison of the effect of uric acid/albumin ratio on coronary colleteral circulation with other inflammation-based markers in stable coronary artery disease patients

BACKGROUND

The Uric acid/Albumin ratio (UAR) has recently been identified as a prominent marker in cardiovascular diseases. In this study, we aimed to reveal the effect of UAR on coronary collateral circulation (CCC) in patients with stable coronary artery disease (CAD) patients by comparing it with conventional inflammation-based markers.

METHODS

In this study, 415 consecutive patients who underwent coronary angiography for stable angina pectoris and were found to have chronic total occlusion in at least one coronary artery were retrospectively included. The study population was divided into two groups as good CCC (Rentrop 2-3) and poor CCC (Rentrop 0-1) according to the Rentrop classification, and the groups were compared in terms of UAR and other traditional inflammation-based markers.

RESULTS

In the poor CCC group, C-reactive protein/albumin ratio (CAR), monocyte/high-density lipoprotein cholesterol ratio (MHR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), systemic immune-inflammation index (SII) and UAR were found to be significantly high (p < .05, for all). UAR negatively correlated with rentrop classification (r = -0.383, p < .001). In multivariate regression analysis, MHR, NLR, SII and UAR were determined as independent predictors for poor CCC (p < .05, for all). The ability of UAR to predict poor CCC was superior to uric acid and albumin alone (p < .0001, for both). In addition, UAR was found to be superior to other inflammation-based markers in predicting poor CCC (p < .005, for all).

CONCLUSION

UAR was identified as a strong and independent predictor of CCC. In this context, UAR may be a useful biomarker in the risk prediction of patients with stable CAD.

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

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

Efficacy and safety of Suxiao Jiuxin Pill in the treatment of stable angina (Qi stagnation and blood stasis syndrome): study protocol of a randomized, double-blind, placebo-controlled, multi-center clinical trial

Background

Coronary heart disease (CHD) has become one of the biggest health problems in the world. Stable angina is a common clinical type of CHD with poor prognosis and high mortality. Although there are various interventions for stable angina, none of them can significantly reduce mortality. Both basic and clinical research have shown that Suxiao Jiuxin Pill (SJP) can relieve the symptoms of angina pectoris and improve the clinical efficacy, but there is a lack of high-quality clinical research to provide research-based evidence. We design a randomized, double-blind, placebo-controlled trial to evaluate the efficacy of SJP for stable angina.

Methods/design

This is a prospective, randomized, double-blind, placebo-controlled, and multicenter trial. The trial will enroll 324 participants with chronic stable angina (Qi Stagnation and Blood Stasis syndrome). All participants will have received the conventional therapy of chronic stable angina. Participants will be randomized into two groups, conventional therapy plus SJP group and conventional therapy plus placebo group. Eligible participants will receive either SJP or placebo (five pills administered orally, three times daily) in addition to conventional treatment for 24 weeks. The primary outcomes are the symptom improvement rate of angina from baseline to 4 weeks after inclusion and major adverse cardiovascular events (MACE). The secondary outcomes are angina classification (CCS), improvement of traditional Chinese medicine (TCM) syndromes, Seattle Angina Scale score, the dosage of emergency drugs and the stopping rate, and electrocardiogram (EKG) efficacy. Adverse events will be monitored throughout the trial.

Discussion

Integrated traditional Chinese and Western Medicine is commonly used for angina in China. This study will evaluate the clinical effectiveness and safety of SJP for angina. The results of the trial will provide high-level clinical research-based evidence for the application of SJP instable angina.

Trial registration

This study protocol was registered on 14 March 2019. The registration number is ChiCTR1900021876 on the Chinese Clinical Trial Registry.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05448-6.

Systemic immune inflammation index: a novel predictor for coronary collateral circulation

AIM

Recently, a new inflammatory and prognostic marker has emerged called as Systemic Immune Inflammation Index (SII). In the current study, we searched the relation between SII and Coronary Collateral Circulation (CCC) formation in stable Coronary Artery Disease (CAD).

MATERIALS & METHODS

449 patients with stable CAD who underwent coronary angiography and documented coronary stenosis of 95% or more in at least one major coronary vessel were included in the study. The study patients were divided into two groups according to the Rentrop score as well CCC (Rentrop 2-3) and bad CCC (Rentrop 0-1). Blood samples for SII and other laboratory parameters were gathered from all the patients on admission. The SII score was formulized as platelet × neutrophil/lymphocyte counts.

RESULTS

Patients, who had developed bad CCC had a higher C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), platelets/lymphocyte ratio (PLR) and SII levels compared to those who had developed well CCC (p < 0.001, for all). Multivariate logistic regression analysis showed that high levels of SII was an independent predictor of bad CCC (OR: 1.005, 95% confidence interval (CI): 1.003-1.006, p < 0.001) together with dyslipidemia, high levels of CRP and NLR. In Receiver Operator Characteristic curve (ROC) analysis, the optimal cutoff value of SII to predict poor CCC was found to be 729.8, with 78.4% sensitivity and 74.6% specificity (area under ROC curve = 0.833 (95% CI: 0.777-0.889, p < 0.001).

CONCLUSION

We have demonstrated that SII, a novel cardiovascular risk marker, might be used as one of the independent predictors of CCC development.

Relationship Between C-Reactive Protein to Albumin Ratio and Coronary Collateral Circulation in Patients With Stable Coronary Artery Disease

We investigated the relationship between the C-reactive protein (CRP) to albumin ratio (CAR) and coronary collateral circulation (CCC) in stable coronary artery disease (CAD). Patients with stable CAD (n = 354) who underwent coronary angiography for suspected CAD and had a total occlusion ≥1 major coronary artery were included in the study. The participants were divided into 2 groups according to the Rentrop score as satisfactory CCC (Rentrop 2-3) and poor CCC (Rentrop 0-1). Patients who had poor CCC had a higher CRP, neutrophil/lymphocyte ratio (NLR), and CAR levels compared with those who had satisfactory CCC (P < .001, P = .046, P < .001, respectively). The CAR (odds ratio: 3.522, 95% CI: 2.515-4.932, P < .001), CRP, NLR, and diabetes mellitus were independent predictors of poor CCC. In receiver operator characteristic curve (ROC) analysis, the optimal cutoff value of CAR to predict poor CCC was 1.27 (area under ROC curve = 0.735 [95% CI: 0.667-0.803], P < .001). A raised CAR may be an independent predictor of poor CCC.

The Role of Nicorandil in the Management of Chronic Coronary Syndromes in the Gulf Region

Chronic coronary syndromes (CCS) and stable angina are a growing clinical burden worldwide. This is of particular concern in the Gulf region given its high prevalence of cardiovascular risk factors, especially diabetes mellitus and smoking. Despite recommendations on the use of first- and second-line anti-anginal medication, management challenges remain. Current guidelines for pharmacologic treatment are not determined by the range of pathophysiological mechanisms of ischaemia and consequent angina, which may occur either in isolation or co-exist. In this article, we highlight the need to improve knowledge of the epidemiology of chronic coronary syndromes in the Middle East and Gulf region, and the need for studies of stratified pharmacologic approaches to improve symptomatic angina and quality of life in the large and growing number of patients with coronary artery disease from this region. We discuss the role of nicorandil, currently recommended as a second-line anti-anginal drug in CCS patients, and suggest that this may be a particularly useful add-on therapy for patients in the Gulf region.

Predictors of recurrent angina in patients with no need for secondary revascularization

BACKGROUND

Approximately 20% to 30% of patients with coronary artery disease (CAD) develop recurrent angina pectoris following successful and complete coronary revascularization utilizing percutaneous coronary intervention (PCI). We aim to investigate predictors of recurrent angina pectoris in patients who have undergone successful coronary revascularization using PCI, but on repeat coronary angiography have no need for secondary revascularization.

METHODS

The study comprised 3,837 patients with CAD, who were enrolled from January 2007 to June 2019. They had undergone successful PCI; some of them redeveloped angina pectoris within one year after the procedure, but on repeat coronary angiography had no need for revascularization. Thrombolysis in myocardial infarction (TIMI) frame count was used to evaluate the velocity of coronary blood in the follow-up angiogram. Multivariate logistic regression was used to investigate risk factors for recurrent angina pectoris. Similarly, predictors of recurrent angina according to the TIMI frame count were assessed using multivariate linear regression.

RESULTS

In this retrospective study, 53.5% of patients experienced recurrent angina pectoris. By multivariate logistic regression, the following characteristics were statistically identified as risk factors for recurrent angina pectoris: female sex, older age, current smoking, low-density lipoprotein cholesterol (LDL-C) ≥1.8 mmol/L, and an elevated TIMI frame count (P for all <0.05). Similarly, using multivariate linear regression, the statistical risk factors for TIMI frame count included: female sex, older age, diabetes, body mass index (BMI), post-procedural treatment without the inclusion of dual antiplatelet therapy.

CONCLUSIONS

Patient characteristics of female sex, older age, diabetes, and elevated BMI are associated with an increased TIMI frame count, coronary microcirculation dysfunction, and recurrent angina pectoris after initially successful PCI. In addition, current smoking and LDL-C ≥1.8 mmol/L are risk factors for recurrent angina pectoris. In contrast, the treatment with dual antiplatelet therapy is negatively correlated with a higher TIMI frame count and the risk of recurrent angina pectoris.

Acupuncture for treating chronic stable angina pectoris-associated anxiety and depression: A protocol for systematic review and meta-analysis

BACKGROUND

There are numerous studies worldwide on the use of acupuncture as complementary therapy for chronic stable angina pectoris (CSAP). However, the high morbidity of CSAP-associated anxiety and depression is often overlooked. This protocol of systematic review and meta-analysis aims to assess whether acupuncture is effective as a complementary therapy for anxiety and depression in patients with CSAP.

METHODS

The following 8 databases will be searched from inception to February 2020 with no language restrictions: PubMed, Excerpt Medical Database, Web of Science, the Cochrane Library, Chinese Biomedical Database, China National Knowledge Infrastructure, VIP Database and Wanfang Database. Eligible randomized controlled trials and controlled clinical trials will be included. Study selection, data extraction, and risk of bias assessment will be performed independently by 2 reviewers, differences will be resolved by the third reviewer. The primary outcomes include the level of anxiety or depression measured by qualified scales, angina attack frequency, and angina pain intensity. Revman 5.3 software will be used to perform the assessment of the risk of bias and data synthesis. The review will grade the quality of the evidence based on the Grading of Recommendation, Assessment, Development, and Evaluation system.

RESULTS

This systematic review and meta-analysis will provide reliable evidence about the effect and safety of acupuncture as a complementary therapy for CSAP-associated anxiety and depression.

CONCLUSION

The conclusion of this study will be published in a peer-reviewed journal.

ETHICS AND DISSEMINATION

This review will not involve private information of participants, so the ethical approval will not be required. The results will be disseminated in a peer-reviewed journal or conference presentation. Important protocol modifications will be updated on PROSPERO.

PROSPERO REGISTRATION NUMBER

CRD42020165492.

Diagnostic performance of deep learning-based vascular extraction and stenosis detection technique for coronary artery disease

OBJECTIVE

To investigate the diagnostic performance of deep learning (DL)-based vascular extraction and stenosis detection technology in assessing coronary artery disease (CAD).

METHODS

The diagnostic performance of DL technology was evaluated by retrospective analysis of coronary computed tomography angiography in 124 suspected CAD patients, using invasive coronary angiography as reference standard. Lumen diameter stenosis ≥50% was considered obstructive, and the diagnostic performances were evaluated at per-patient, per-vessel and per-segment levels. The diagnostic performances between DL model and reader model were compared by the areas under the receiver operating characteristics curves (AUCs).

RESULTS

In patient-based analysis, AUC of 0.78 was obtained by DL model to detect obstructive CAD [sensitivity of 94%, specificity of 63%, positive predictive value of 94%, and negative predictive value of 59%], While AUC by reader model was 0.74 (sensitivity of 97%, specificity of 50%, positive predictive value of 93%, negative predictive value of 73%). In vessel-based analysis, the AUCs of DL model and reader model were 0.87 and 0.89 respectively. In segment-based analysis, the AUCs of 0.84 and 0.89 were obtained by DL model and reader model respectively. It took 0.47 min to analyze all segments per patient by DL model, which is significantly less than reader model (29.65 min) (p < 0.001).

CONCLUSION

The DL technology can accurately and effectively identify obstructive CAD, with less time-consuming, and it could be a reliable diagnostic tool to detect CAD.

ADVANCES IN KNOWLEDGE

The DL technology has valuable prospect with the diagnostic ability to detect CAD.

Adenoviral Gene Transfer of Gremlin Modulates Vascular Endothelial Growth Factor-A-Induced Angiogenesis in Porcine Myocardium

Coronary artery disease is a major cause of death and disability worldwide. New therapies are needed for patients who do not benefit or are not suitable for current treatments. Angiogenic gene therapy using vascular endothelial growth factors (VEGFs) has shown potential in preclinical trials. However, undesired side effects, such as increased permeability, limit their therapeutic potential. The aim of this study was to investigate if adenoviral gene transfer of a VEGF receptor 2 (VEGFR-2) ligand Gremlin, given simultaneously with VEGF-A, could modulate VEGFR-2-mediated increase in permeability without impairing the angiogenic effect of VEGF-A gene therapy. Gene transfers were done in pigs (n = 22) using endocardial injections with an endovascular injection catheter. Animals were divided in three groups receiving adenoviral (Ad) VEGF-A (n = 10), Gremlin (n = 6), or VEGF-A+Gremlin (n = 6) gene therapy. Animals were sacrificed and samples collected 6 days later for histological, safety, and permeability analyses. The mean capillary area was significantly increased in both treatment groups with AdVEGF-A when compared with the AdGremlin group. Also, the capillary area was significantly larger in AdVEGF-A group without AdGremlin. No significant differences in tissue permeability were observed using modified Miles assay between AdVEGF-A and AdVEGF-A+AdGremlin groups. However, cardiac tamponade and sudden cardiac deaths were observed only in the AdVEGF-A group. AdVEGF-A induces strong angiogenesis in porcine myocardium. Our results suggest that AdGremlin can limit the side effects of AdVEGF-A therapy, even though no direct effect on tissue permeability could be demonstrated. This could enable the use of larger AdVEGF-A doses to increase the treatment area and angiogenic effects without adverse side effects.

Anti-anginal drugs: Systematic review and clinical implications

BACKGROUND

The cornerstone of the treatment of patients affected by stable angina is based on drugs administration classified as first (beta-blockers, calcium channel blockers, short acting nitrates) or second line treatment (long-acting nitrates, ivabradine, nicorandil, ranolazine and trimetazidine). However, few data on comparison between different classes of drugs justify that one class of drugs is superior to another.

METHODS

We performed a systematic review of the literature following PRISMA guidelines.

INCLUSION CRITERIA

i) paper published in English; ii) diagnosis of stable coronary disease; iii) randomized clinical trial; iv) comparison of two anti-angina drugs; v) a sample size >100 patients; vi) a follow-up lasting at least 2 weeks; vii) paper published after 1999, when a meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina of Heidenreich et al. was published.

OUTCOME

to establish whether the categorization in first and second line antianginal treatment is scientifically supported.

RESULTS

Eleven trials fulfilled inclusion criteria. The results show that there is a paucity of data comparing the efficacy of antianginal agents. The little data available show that there are not compounds superior to others in terms of improvement in exercise test duration, frequency of anginal attacks, need for sub-lingual nitroglycerin.

CONCLUSION

The categorization of antianginal drug in first and second line is not confirmed.

Sta Ble Angina: Pe Rcept Ion of Nee Ds, Quality of Life and Mana Gem Ent of Patients (BRIDGE Study)-A Multinational European Physician Survey

Stable angina (SA) is a chronic condition reducing physical activity and quality of life (QoL). Physicians treating patients with SA in Italy, Germany, Spain, and United Kingdom completed a web-based survey. The objective was to assess physician perceptions of patient needs, the impact of SA on QoL, and evaluate SA management. Overall, 659 physicians (cardiologists and general practitioners) entered data from 1965 eligible patients. The perceived importance of everyday activities for patients with a recent diagnosis (≤2 years) was higher than for patients with a longer diagnosis (>2 years), while severity of limitations for those activities were rated similarly for both groups. Gender-based analyses revealed that physicians documented more severe SA, more symptoms and more angina attacks in women, yet they rated the patients' condition as similar for both sexes. Women also received less medical and interventional treatment. Patients who have previously had a percutaneous coronary intervention (PCI) had more severe SA, despite more intense medical treatment, than patients with no previous PCI. In conclusion, severity, symptoms, and impact of SA on health status and everyday life activities vary by duration of disease, gender, and previous PCI. However, physicians do not seem to attach appropriate importance to these differences.

Treatment of Angina: Where Are We?

Ischaemic heart disease is a major cause of death and disability worldwide, while angina represents its most common symptom. It is estimated that approximately 9 million patients in the USA suffer from angina and its treatment is challenging, thus the strategy to improve the management of chronic stable angina is a priority. Angina might be the result of different pathologies, ranging from the “classical” obstruction of a large coronary artery to alteration of the microcirculation or coronary artery spasm. Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revascularization. In the current guidelines, drugs are classified as being first-choice (beta-blockers, calcium channel blockers, and short-acting nitrates) or second-choice (ivabradine, nicorandil, ranolazine, trimetazidine) treatment, with the recommendation to reserve second-line modifications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. However, such a categorical approach is currently questioned. In addition, current guidelines provide few suggestions to guide the choice of drugs more suitable according to the underlying pathology or the patient comorbidities. Several other questions have recently emerged, such as: is there evidence-based data between first- and second-line treatments in terms of prognosis or symptom relief? Actually, it seems that newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than what is available for the first-choice drugs. It follows that actual guidelines are based more on tradition than on evidence and there is a need for new algorithms that are more individualized to patients, their comorbidities, and pathophysiological mechanism of chronic stable angina.

Effectiveness and safety of anti-ischemic trimetazidine in patients with stable angina pectoris and Type 2 diabetes

Aim & methods: This 6-month prospective, observational, noninterventional, open-label clinical study assessed the effectiveness/safety of trimetazidine in 737 patients with stable angina pectoris and Type 2 diabetes mellitus (OGYI/51534–1/2014). Results: Trimetazidine-based therapy was effective in stable coronary artery disease, with significant improvements from baseline (p < 0.05) in: number of angina attacks/week (2.9 ± 2.4 vs 1.1 ± 1.6), angina severity (Canadian Cardiovascular Society Classification 1.9 ± 0.8 vs 1.2 ± 0.8), exercise capacity (metabolic equivalents 6.1 ± 1.7 vs 6.5 ± 1.7), and exercise-induced myocardial ischemia (min 5.5 ± 2.5 vs 6.5 ± 2.6). Discussion: Trimetazidine treatment significantly (p < 0.05) improved glucose metabolism, lowered HbA1c (7.1 ± 1.1% vs 6.6 ± 1.0%), glucose levels (7.7 ± 2.1 mmol/l vs 6.9 ± 1.6 mmol/l) and decreased arterial stiffness (pulse wave velocity 11.2 ± 2.1 m/s vs 10.4 ± 2.2 m/s). In most patients, the tolerability of trimetazidine was rated as excellent to good, with a low incidence of adverse events.

[Triple antianginal combinations in the treatment of elderly and senile patients with stable angina]

AIM

To compare the efficiency and safety of antianginal therapy (AAT) using a combination of bisoprolol, ivabradine, and trimetazidine or ranolazine in elderly and senile patients with stable angina.

SUBJECTS AND METHODS

The study enrolled 107 patients aged 60 to 79 years with coronary heart disease and Functional Class II and III angina. When the patients taking bisoprolol 1.25-2.5 mg once daily and ivabradine 2.5-7.5 mg twice daily continued to have angina and/or silent myocardial ischemia, after randomization 54 patients received an additional 35 mg of trimetazidine twice a day and 53 patients had ranolazine 500 mg twice daily. A comprehensive clinical and instrumental study was conducted prior to randomization and after 6 months of triple AAT.

RESULTS

The patients tolerated well both treatments that substantially improved the results of a treadmill exercise test. Trimetazidine reduced to a greater extent the duration of silent ST-segment depression, as evidenced by Holter monitoring. Trimetazidine and ranolazine comparably improved left ventricular systolic and diastolic function, large arterial structure and function, and quality of life in the patients.

CONCLUSION

The combinations of the low-dose β-blocker with ivabradine and trimetazidine or ranolazine may be used to treat refractory stable angina in elderly and senile patients. Trimetazidine is preferred due to its higher efficacy in treating silent myocardial ischemia and to its lower cost.

Experimental and early investigational drugs for angina pectoris

INTRODUCTION

Ischemic heart disease (IHD) is a major cause of death and disability among Western countries and angina pectoris is the most prevalent symptomatic manifestation. Strategies to improve management of chronic stable angina are a priority. Areas covered: A comprehensive review was conducted using the Medline and Cochrane databases as well as the clinical trial databases in the United States and Europe. Traditional therapies for angina will be discussed. This review particularly emphasizes investigational therapies for angina (including pharmacological agents, cell and gene based therapies, and herbal medications). Expert opinion: There has been renewed interest in older anti-angina agents (e.g., perhexiline, amiodarone, and phosphodiestrase-5 inhibitors). Other anti-inflammatory agents (e.g., allopurinol and febuxostat) are currently undergoing evaluation for angina therapy. Therapeutic angiogenesis continues to face some challenges. Future trials should evaluate the optimum patient population that would benefit from this form of therapy.