Stable Angina Medical Therapy Management Guidelines: A Critical Review of Guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Do Clinical Outcomes and Quality of Life Differ by the Number of Antianginals for Stable Ischemic Heart Disease? Insights from the BARI 2D Trial

Medical therapy, including antianginal treatment, is the cornerstone in the management of stable ischemic heart disease (SIHD). However, it remains unclear whether combining antianginal agents provides benefits beyond monotherapy in terms of quality of life (QoL) and cardiovascular outcomes. We used data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, which compared cardiovascular and QoL outcomes in patients with SIHD and diabetes mellitus randomized to revascularization with intensive medical therapy or intensive medical therapy alone. We categorized patients into 3 groups: ≥2 versus 1 versus 0 antianginals. We compared patient characteristics, QoL metrics, and cardiovascular end points at baseline and at 5 years, creating a multivariable model to adjust for key clinical confounders. Of 2,368 patients, 348 patients (14.7%) were on 0 antianginals, 1,020 patients (43.1%) were on 1 antianginal, and 1,000 patients (42.2%) were on ≥2 antianginals at baseline. The most common antianginal class was β blockers. At baseline, patients on 0 antianginals had better QoL metrics (self-health score, Duke activity status index, and energy rating) than patients on ≥2 antianginals. However, at the 1-year follow-up, patients taking only 1 antianginal showed greater QoL improvement than those taking 0 antianginal, without any incremental benefit in QoL metrics seen in patients taking ≥2 antianginal agents, even after adjusting for multiple covariates such as age, heart failure, diabetes control, and myocardial jeopardy index. Lastly, at the 5-year follow-up, after adjustment, there were no differences in all-cause mortality, major adverse cardiovascular events, or myocardial infarction between patients taking different numbers of antianginals. Adults on a single antianginal for SIHD and diabetes mellitus had similar or better improvements in QoL than those on 2 or more antianginal agents at 1 year of follow-up. These findings merit further research to better understand the impact of medical therapy intensity on QoL in patients with SIHD and associated co-morbidities.

The Development of a Chest-Pain Protocol for Women Presenting to the Emergency Department

Cardiovascular disease (CVD) is the leading cause of death in women worldwide, and of premature death in women in Canada. Despite improvements in cardiovascular care over the past 15-20 years, acute coronary syndrome (ACS) and CVD mortality continue to increase among women in Canada. Chest pain is a common symptom leading to emergency department visits for both men and women. However, women with ACS experience worse outcomes. compared with those of men, due to misdiagnosis or lack of diagnosis resulting in delayed care and underuse of guideline-directed medical therapies. CVD mortality rates are highest in Indigenous and racialized women and those with a disproportionately high number of adverse social determinants of health. CVD remains underrecognized, underdiagnosed, undertreated, and underresearched in women. Moreover, a lack of awareness of unique symptoms, clinical presentations, and sex-and-gender specific CVD risk factors, by healthcare professionals, leads to outcome disparities. In response to this knowledge gap, in acute recognition and management of chest-pain syndromes in women, the Canadian Women's Heart Health Alliance performed a needs assessment and review of CVD risk factors and ACS pathophysiology, through a sex and gender lens, and then developed a unique chest-pain assessment protocol utilizing modified dynamic programming algorithmic methodology. The resulting algorithmic protocol is presented. The output is intended as a quick reference algorithm that could be posted in emergency departments and other acute-care settings. Next steps include protocol implementation evaluation and impact assessment on CVD outcomes in women.

Cost-Effectiveness of Vonoprazan Compared With Proton Pump Inhibitors in Patients Taking Low-Dose Aspirin for Secondary Prevention of Cardiovascular Events in Japan

BACKGROUND

Low-dose aspirin (LDA) is used to prevent recurrent cardiovascular (CV) events, but is associated with upper gastrointestinal (GI) bleeding; concomitant use of a proton pump inhibitor (PPI) reduces this risk. This study aimed to assess the cost-effectiveness of vonoprazan compared with PPIs (lansoprazole and esomeprazole) in patients taking LDA for secondary prevention of CV events.Methods and Results: A Markov simulation model was developed to predict the number of GI bleeding and acute CV events using 3 strategies (vonoprazan+LDA, esomeprazole+LDA, and lansoprazole+LDA), which were translated into quality-adjusted life-years (QALYs) and costs. Transition probabilities and utilities were derived from the results of published literature, and medical costs were based on the Japanese National Health Insurance fee table and claims databases in 2020. Outcomes were projected over 30 years starting at age 65 years and discounted at 2% annually. Expected costs with esomeprazole 20 mg, lansoprazole 15 mg and vonoprazan 10 mg were JPY 1,225,657, JPY 943,930, and JPY 1,059,510, respectively. The QALY gain for vonoprazan vs. esomeprazole was 0.35, thus vonoprazan was dominant against esomeprazole. The QALY gain for vonoprazan vs. lansoprazole was 0.29 and the incremental cost-effectiveness ratio (ICER) was JPY 398,551, thus, vonoprazan was more cost-effective than lansoprazole.

CONCLUSIONS

Vonoprazan is dominant or cost-effective compared with esomeprazole and lansoprazole in patients taking LDA for secondary prevention of CV events.

Combination of Nicorandil and Beta-Adrenergic Receptor Blockers in Patients with Coronary Artery Disease: A Real-World Observational Study

BACKGROUND

The effect of combined nicorandil and beta-adrenergic receptor blockers (BBs) compared with that of BBs alone on long-term clinical outcomes in patients with coronary artery disease (CAD) remains undetermined.

METHODS

A multicenter retrospective cohort study was performed. Adult patients who had been hospitalized for CAD and treated for angina with a combination of nicorandil and BBs or BBs alone were included. The effect of different treatments on the cumulative incidence of major adverse cardiovascular event (MACE) and their components within a follow-up duration of 2.5 years were analyzed using Kaplan-Meier survival curves. An inverse probability of treatment weighting (IPTW) method was used to adjust for the possible effect of confounding factors.

RESULTS

A total of 137,714 patients were screened, of whom 16,912 individuals (mean age: 61.5 years, men: 67.1%) were successfully enrolled. Among the enrolled participants, 4669 received the combined treatment of nicorandil and BBs, while 12,243 received BBs alone. After IPTW, the results demonstrated that the combined treatment was associated with a significantly reduced incidence of MACE (hazard ratio [HR] 0.79, 95% conidence interval [CI] 0.72-0.87) and stroke (HR 0.48, 95% CI 0.42-0.54) but not of MI (HR 1.03, 95% CI 0.92-1.15) or all-cause mortality (HR 0.93, 95% CI 0.64-1.37). Sensitivity analyses revealed similar results.

CONCLUSIONS

A combined antiangina treatment of nicorandil and BBs may be more effective than treatment of BBs alone in reducing the long-term incidence of MACE in patients with CAD.

Predictive significance and diagnostic accuracy of plasma fibrinogen levels for coronary stenting outcomes

Objective: The advancement in percutaneous transluminal coronary angioplasty (PTCA) has led to it becoming the predominant mode of revascularization. Post PTCA adverse events in the form of stent thrombosis, recurrent ischemia, unplanned revascularization, recurrent hospitalization etc. result in morbidity as well as mortality. Biomarkers predicting such outcomes can be useful in initiating more aggressive medical therapy and greater modification of risk factors. This study was undertaken to study the predictive significance of periprocedural plasma fibrinogen levels for coronary stenting outcomes. Methods: 80 patients diagnosed as either chronic stable angina (CSA), unstable angina (UA), Non ST Elevation Myocardial Infarction (NSTEMI) or late presentation ST Elevation Myocardial Infarction (STEMI) undergoing planned PTCA were included in study. Patients were evaluated for clinical history, electrocardiogram (ECG), two dimensional echocardiography (2D-echo) and cardiac biomarkers (Creatinine Phorphokinase-MB isomer (CK-MB) and Troponin I). Serum fibrinogen level was measured 24 hours prior to PTCA along with routine pre-operative investigations; and also 24 hours after coronary stenting. Patients were followed for six months. Outcome measure was taken to be freedom from cardiac related adverse events, including rehospitalisation, unplanned repeat revascularization, definite stent thrombosis, transient ischemic attack, stroke and all-cause mortality. Results:  Fibrinogen level ≥393 mg/dL, 24 hours prior to percutaneous transluminal coronary angioplasty, was associated with higher major adverse cardiac and cerebrovascular events (MACCE) rates (60%) as compared to those with fibrinogen level &lt;393 mg/dL (3.6%).  Fibrinogen level ≥427 mg/dL 24 hours after percutaneous transluminal coronary angioplasty, was associated with higher major adverse cardiac and cerebrovascular events rates (65%) as compared to those with fibrinogen level &lt;427 mg/dL (6.7%). Conclusion: The current study demonstrates that higher baseline and post procedural fibrinogen, is an independent predictor of 6 months major adverse cardiac and cerebrovascular events after elective percutaneous coronary intervention. Key words:  Coronary stent outcomes, major adverse cardiac and cerebrovascular events, plasma fibrinogen, stent diameter

The Potential Prognostic, Diagnostic and Therapeutic Targets for Recurrent Arrhythmias in Patients with Coronary Restenosis and Reocclusions After Coronary Stenting

BACKGROUND

The interplay of oxidative stress, proinflammatory microparticles, and proinflammatory cytokines in recurrent arrhythmias is unknown in elderly patients with coronary restenosis and reocclusions after coronary stenting.

OBJECTIVE

This research sought to investigate the potential diagnostic and therapeutic targets for recurrent arrhythmias in patients with coronary restenosis and reocclusions after coronary stenting.

METHODS

We examined whether oxidative stress, proinflammatory microparticles, and proinflammatory cytokines could have effects that lead to recurrent arrhythmias in elderly patients with coronary restenosis and reocclusions. We measured the levels of malondialdehyde (MDA), CD31 + endothelial microparticle (CD31 EMP), CD62E + endothelial microparticle (CD62E + EMP), high-sensitivity C-reactive protein (hs-CRP), interleukin- 1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α), as well as oxidized low-density lipoprotein (OX-LDL), and assessed the effects of relationship between oxidative stress, proinflammatory microparticles, and proinflammatory cytokines on recurrent atrial and ventricular arrhythmias in elderly patients with coronary restenosis and reocclusions after coronary stenting.

RESULTS

The levels of CD31 + EMP, CD62E + EMP, MDA, hs-CRP, IL-1β, IL-6, IL-8, TNF-α and OX-LDL were found to be increased significantly in coronary restenosis + recurrent atrial arrhythmia group compared to without coronary restenosis and coronary restenosis + without recurrent atrial arrhythmia groups, respectively (P < 0.001). Patients in the coronary reocclusion + recurrent ventricular arrhythmia group also exhibited significantly increased levels of CD31 + EMP, CD62E + EMP, MDA, hs-CRP, IL-1β, IL-6, IL-8, TNF-α and OXLDL compared to without coronary reocclusion and coronary reocclusion + without recurrent ventricular arrhythmia groups, respectively (P < 0.001).

CONCLUSION

Proinflammatory microparticles, proinflammatory cytokines, and oxidative stress might act as potential targets for recurrent arrhythmias in patients with coronary restenosis and reocclusions after coronary stenting.

Clinical impact of cardiac magnetic resonance in patients with suspected coronary artery disease associated with chronic kidney disease (AQUAMARINE-CKD study): study protocol for a randomized controlled trial

Background

Although screening for coronary artery disease (CAD) using computed tomography coronary angiography in patients with stable chest pain has been reported to be beneficial, patients with chronic kidney disease (CKD) might have limited benefit due to complications of contrast agent nephropathy and decreased diagnostic accuracy as a result of coronary artery calcifications. Cardiac magnetic resonance (CMR) has emerged as a novel imaging modality for detecting coronary stenosis and high-risk coronary plaques without contrast media that is not affected by coronary artery calcification. However, the clinical use of this technology has not been robustly evaluated.

Methods

AQUAMARINE-CKD is an open parallel-group prospective multicenter randomized controlled trial of 524 patients with CKD at high risk for CAD estimated based on risk factor categories for a Japanese urban population (Suita score) recruited from 6 institutions. Participants will be randomized 1:1 to receive a CMR examination that includes non-contrast T1-weighted imaging and coronary magnetic angiography (CMR group) or standard examinations that include stress myocardial scintigraphy (control group). Randomization will be conducted using a web-based system. The primary outcome is a composite of cardiovascular events at 1 year after study examinations: all-cause death, death from CAD, nonfatal myocardial infarction, nonfatal ischemic stroke, and ischemia-driven unplanned coronary intervention (percutaneous coronary intervention or coronary bypass surgery).

Discussion

If the combination of T1-weighted imaging and coronary magnetic angiography contributes to the risk assessment of CAD in patients with CKD, this study will have major clinical implications for the management of patients with CKD at high risk for CAD.

Trial registration

Japan Registry of Clinical Trials (jRCT) 1,052,210,075. Registered on September 10, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06820-w.

Identifying Drug-Therapy Problems among Syrian Refugees in Zaatari Refugee Camp

Background: Due to a lack of proper pharmaceutical care, Syrian refugees in the Zaatari refugee camp are more likely to have drug-related issues, such as prescription errors and adverse drug occurrences. Aim: The current study aims to identify drug-therapy problems among Syrian refugees in the Zaatari refugee camp. Method: This is a retrospective cross-sectional study. Patients’ files were collected from the Zaatari camp database. Patients who were 18 years or older and were previously diagnosed with a chronic disease were included. A classification of drug therapy problems (DTPs) was adapted. Results: The data of 1530 adult patients (896 females) were collected. The mean age of the sample was 53.7 years and the mean Body mass Index (BMI) was 27.20. The mean of all taken medications was 4.01 (±2.33) medications, with a maximum number of 13. A total of 3572 DTPs was identified, with a mean of 2.33 (±1.26) DTPs per patient. Based on the above-mentioned classification, 70.32% of the DTPs were related to indication, 26.65% were related to effectiveness, and 3.03% were related to safety. Conclusion: This study found that refugees in the Zaatari refugee camp have numerous DTPs among their medications. Greater focus should be placed on their medical care, in order to prevent any future complications due to DTPs.

Comparison of Buyang Huanwu granules and Naoxintong capsules in the treatment of stable angina pectoris: rationale and design of a randomized, blinded, multicentre clinical trial

BACKGROUND

Stable angina pectoris (SAP) currently seriously threatens the health of humans, and mortality is continuously rising. Current treatment strategies mainly include pharmaceutical therapy and revascularization. In China, Buyang Huanwu granules (BYHW) and Naoxintong capsules (NXT) have been used in the treatment of SAP, but it is not clear which agent is better in terms of relieving symptoms and improving quality of life. Therefore, we designed a clinical trial to compare the efficacy and safety of NXT and BYHW in the treatment of SAP.

METHODS

This is a randomized, blinded, parallel controlled, multicentre clinical trial protocol. On the basis of standardized Western medicine treatment, a total of 128 SAP patients will be randomly divided into intervention group 1 (NXT group), intervention group 2 (BYHW group), and a control group (placebo group) at a 2:1:1 ratio. A 2-week run-in period is required prior to randomization, and a 1-week baseline period and 4-week treatment period are included in this study. The primary outcome is the efficacy rate of stable angina symptom score improvement; the secondary outcomes include the effect on electrocardiograms, Seattle Angina Questionnaire scores, and nitroglycerine consumption.

DISCUSSION

This study will evaluate the efficacy and safety of NXT and BYHW in the treatment of SAP. The results will provide critical evidence for using Chinese herbal medicines to treat SAP.

TRIAL REGISTRATION

Chinese Clinical Trials Registry ChiCTR1800015191. Registered on 13 March 2018. http://www.chictr.org.cn/showproj.aspx?proj=25818 . All the registration items can be found within the protocol.

Clinical Implications of Nicorandil Combined with Trimetazidine in Patients with Coronary Heart Disease: A Real-World Observational Study

INTRODUCTION

Coronary heart disease (CHD) remains the leading cause of mortality in China. The treatment strategies, especially for patients with ischemic angina pectoris, are still far from satisfactory. Hence, this study was carried out to evaluate the long-term potential of nicorandil in Chinese patients with CHD.

METHODS

Adult patients with CHD were reviewed retrospectively from three hospitals in Central China to obtain relevant data. The primary outcome was the rate of major adverse cardiovascular events (MACE) which is the composite outcome of stroke, myocardial infarction (MI), and mortality at 3 years while the secondary outcomes included rates of MACE, stroke, MI, and mortality at 1 and 2 years. The rates of MACE were estimated using Kaplan-Meir survival curves and compared by log-rank test. The association between various treatment regimens and hazards of MACE was estimated using Cox proportional hazards model. All analyses were carried out using SAS 9.4.

RESULTS

A total of 5504, 1674, and 3923 patients treated with the nicorandil-trimetazidine combination, nicorandil, and trimetazidine were included in the study, respectively. At 3-year follow-up, the rate of MACE [hazard ratio (HR) 0.85; 95% CI 0.74-0.97; P = 0.017] and stroke (HR 0.58, 95% CI 0.48-0.71; P < 0.0001) was lower in the combination group compared to trimetazidine group. Similarly, the rate of stroke was significantly lower (HR 0.69; 95% CI 0.52-0.93; P = 0.0146) at 3 years in the nicorandil group compared to the trimetazidine group. The rate of stroke (HR 0.65; 95% CI 0.52-0.83; P = 0.0004) was significantly lower among the combination group compared with the trimetazidine group at 1-year follow-up. Similarly, the rate of stroke was significantly lower at 1 year (HR 0.70; 95% CI 0.50-0.97; P = 0.03) but not at 2 years (HR 0.70; 95% CI 0.52-0.94; P = 0.0177), while the rate of other outcomes, though lower in the nicorandil group than the trimetazidine group, was not statistically significant at 1 and 2 years respectively.

CONCLUSION

Nicorandil in combination with trimetazidine can be considered as an effective and potential treatment strategy in reducing the rate of MACE in patients with CHD in the Chinese population.

Plasma Leukocyte Cell-Derived Chemotaxin 2 (LECT2) as a Risk Factor of Coronary Artery Disease: A Cross-Sectional Study

Many studies have shown that leukocyte cell-derived chemotaxin 2 (LECT2) is associated with metabolic disorders, which is a risk factor of arteriosclerosis. We assessed the level of LECT-2 in patients with coronary artery disease (CAD) and its severity and prognosis. We selected 666 participants who underwent coronary angiography in our hospital and included patients with non-CAD, patients with stable angina pectoris (SAP), patients with unstable angina (UA), patients with non-ST-segment elevation myocardial infarction (NSTEMI) and patients with ST-segment elevation myocardial infarction (STEMI). The serum level of LECT-2 was higher in patients with CAD than in patients with non-CAD and was an independent predictor for CAD. Subgroup analysis showed that compared with the SAP group, the UA, NSTEMI, and STEMI groups had higher serum levels of LECT-2. In addition, the level of LECT-2 was related to the SYNTAX score and SYNTAX II score. Finally, patients with acute myocardial infarction (AMI) with elevated levels of LECT-2 had a higher risk of major adverse cardiovascular events (MACEs) within 12 months than those with lower levels of LECT-2. Plasma LECT-2 levels may be useful for the diagnosis of CAD and as predictors of MACE in patients with AMI.

Multicomponent Cardiac Rehabilitation and Cardiovascular Outcomes in Patients With Stable Angina: A Systematic Review and Meta-analysis

Objective

To carry out a systematic review of the effect of cardiac rehabilitation (CR) and its components on cardiovascular outcomes in patients with stable angina.

Methods

We searched the databases including Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL from their inception up to November 1, 2017. The search was not restricted to time or publication status but was limited to the English language. Two independent investigators screened the identified studies and extracted the data in duplicate. We reviewed the included studies and, where possible, pooled their results and conducted meta-analyses. Risk of bias was assessed using Cochrane Collaboration tools.

Results

The search identified 7508 studies. Ten randomized trials including 4005 participants with the mean (SD) age of 59.6 (5.7) years were considered eligible for inclusion in our analyses. The results of meta-analyses of exercise-based CR for patients with stable angina revealed that CR improved exercise capacity (the difference between baseline and follow-up was 0.76 watt [0.49 to 1.02] higher in the CR group vs the non-CR group) and decreased angina frequency (standard mean difference, -0.27 [CI, -0.43 to 0.11]). No significant differences were noted in other outcomes, including quality of life. Mortality could not be adequately assessed because it was analyzed in only 1 exercise-based CR study.

Conclusion

Our systematic review, involving a relatively small number of studies with low to moderate risk of bias and with considerable heterogeneity, found a significant decrease in angina frequency and increase in exercise capacity in patients with stable angina who participated in an exercise-based CR program. Studies involving the impact of components of CR are limited and generally report beneficial outcomes. Additional studies are needed to clarify the possible role of CR in the management of patients with stable angina.

Analysis of Risk Factors in Patients with Subclinical Atherosclerosis and Increased Cardiovascular Risk Using Factor Analysis

Today, there are many parameters used for cardiovascular risk quantification and to identify many of the high-risk subjects; however, many of them do not reflect reality. Modern personalized medicine is the key to fast and effective diagnostics and treatment of cardiovascular diseases. One step towards this goal is a better understanding of connections between numerous risk factors. We used Factor analysis to identify a suitable number of factors on observed data about patients hospitalized in the East Slovak Institute of Cardiovascular Diseases in Košice. The data describes 808 participants cross-identifying symptomatic and coronarography resulting characteristics. We created several clusters of factors. The most significant cluster of factors identified six factors: basic characteristics of the patient; renal parameters and fibrinogen; family predisposition to CVD; personal history of CVD; lifestyle of the patient; and echo and ECG examination results. The factor analysis results confirmed the known findings and recommendations related to CVD. The derivation of new facts concerning the risk factors of CVD will be of interest to further research, focusing, among other things, on explanatory methods.

By discontinuing beta-blockers before an exercise test we may precipitate a rebound phenomenon

BACKGROUND

There is a need to analyse the current approach to beta-blocker (BB) use in relation to exercise-based stress tests.

OBJECTIVE

We compared various guidelines regarding recommending abrupt vs gradual discontinuation of BB prior to exercise tests. We also analyse the shortcomings of the currently recommended approach and suggest a new approach to avoid BB rebound.

METHODS

A narrative review is used to analyse this topic due to lack of valid randomized clinical trials.

RESULTS

Omitting the BB therapy prior to exercise-based test has been recommended in guidelines for many years. Although reasonable, this approach has potential disadvantages since sudden BB withdrawal may induce a rebound phenomenon, which is, also, acknowledged in several guidelines.

CONCLUSIONS

We observed inconsistency among relevant guidelines; there is no homogenous approach regarding BB use before exercise tests. Most guidelines recommend BB withdrawal for a couple of days before the test; they do not advise BB dose tapering. This approach is not standardised and raises the risk of BB rebound phenomenon both before and during the test. Therefore, we suggest using the half the prescribed BB dose at the usual time of administration (in the morning, prior to the exercise test).

The Clinical Efficacy of Phytochemical Medicines Containing Tanshinol and Ligustrazine in the Treatment of Stable Angina: A Systematic Review and Meta-Analysis

BACKGROUND

Phytochemical medicines containing tanshinol and ligustrazine are commonly used in the treatment of stable angina in China, but their clinical effectiveness and risk have not been adequately assessed. In this paper, we conducted a systematic review and meta-analysis to evaluate the clinical efficacy.

METHODS

Relevant randomized controlled trials (RCTs) of phytochemical medicines containing tanshinol and ligustrazine in the treatment of stable angina were searched in electronic databases. The search date was up to March 31, 2020, and the languages of the RCTs were limited to English and Chinese.

RESULTS

A total of 28 studies, including 2518 patients, were included in the meta-analysis. It was shown that the adjunctive therapy of phytochemical medicines containing tanshinol and ligustrazine was better than the conventional therapies in the improvement of stable angina according to the clinical efficacy in symptoms (n = 2518, RR = 1.24, 95% CI: 1.20 to 1.29, P < 0.01) and clinical efficacy in electrocardiography (n = 1766, RR = 1.29, 95% CI: 1.19 to 1.40, P < 0.01).

CONCLUSION

The meta-analysis supported the use of phytochemical medicines containing tanshinol and ligustrazine in the treatment of stable angina. However, quality of the evidence for this finding was low due to a high risk of bias in the included studies. Therefore, well-designed RCTs are still needed to further evaluate the efficacy.

Acupuncture and related therapies for treating stable angina pectoris: A protocol of an overview of systematic reviews and meta-analysis

BACKGROUND

Stable angina pectoris (SAP) is a global health challenge. Multiple previous systematic reviews (SRs) have been conducted to assess the effectiveness of acupuncture and related therapies on SAP. We will carry out a comprehensive overview to map, synthesize, and assess the all the available evidence of acupuncture and related therapies on SAP.

METHODS

We will search 7 databases, including China National Knowledge Infrastructure (CNKI) and Chinese Biomedical Literature Database (CBM), WanFang Database, the Cochrane Library, PubMed, EMbase, MEDLINE. SRs and meta-analyses (MAs) of acupuncture and related therapies on SAP will be screened for eligibility. Systematic reviews, qualification evaluation, data extraction, methodological quality, and evidence quality evaluation will be conducted in pairs. The outcomes of interest include: frequency of angina attack, changes in nitroglycerin use, intensity of anginal pain, depression assessment, changes of the electrocardiogramme (ECG), anxiety assessment, results of the Six-Minute Walk Test (6-MWT), overall effectiveness, the Seattle Angina Questionnaire (SAQ), and adverse events. Where appropriate, the evidence will be synthesized based on the outcomes and patient subgroups.

RESULTS

This overview will be published in a peer-reviewed journal.

CONCLUSION

This overview is expected to provide a reliable and valuable evidence of acupuncture for treating SAP.

ETHICS AND COMMUNICATION

Given that this is an overview of published research, patient consent and ethical approval are not needed. The findings of this study will be disseminated through conference presentations and publication in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42020164466.

Association Between Plasma ADAMTS-9 Levels and Severity of Coronary Artery Disease

Genome-wide association studies have shown that a disintegrin and metalloproteinase with thrombospondin motifs 9 (ADAMTS-9) is associated with the development of atherosclerosis. We assessed the level of ADAMTS-9 in patients with coronary artery disease (CAD) and its severity and prognosis. We selected 666 participants who underwent coronary angiography in our hospital and met the inclusion and exclusion criteria; participants included non-CAD patients, patients with stable angina pectoris (SAP), unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation myocardial infarction. The serum level of ADAMTS-9 was higher in patients with CAD than in non-CAD patients (37.53 ± 8.55 ng/mL vs 12.04 ± 7.02 ng/mL, P < .001) and was an independent predictor for CAD (odds ratio = 1.871, 95% CI: 1.533-2.283, P < .001). Subgroup analysis showed that compared with the SAP group, the acute coronary syndrome groups had higher serum levels of ADAMTS-9. In addition, the level of ADAMTS-9 was related to the SYNTAX score (r = 0.523, P < .001). Patients with acute myocardial infarction (AMI) with elevated levels of ADAMTS-9 had a higher risk of major adverse cardiovascular events (MACE) within 12 months than those with lower levels (log-rank = 4.490, P = .034). Plasma ADAMTS-9 levels may be useful for the diagnosis of CAD and as predictors of MACE in AMI patients.

Chinese Herbal Formula Xuefu Zhuyu for Stable Angina (CheruSA): Study Protocol for a Multicenter Randomized Controlled Trial

Introduction. Stable angina (SA) in coronary heart disease is a common ischemic heart disease endangering the patient's quality of life and longevity. Clinical trials have demonstrated that the Chinese herbal formula Xuefu Zhuyu (XFZY) has benefits for SA patients. However, there remains a lack of high-quality evidence to support clinical decision-making. Therefore, we designed a randomized controlled trial (RCT) to evaluate the efficacy and safety of XFZY for SA. Methods and Analysis. This multicenter, double-blinded RCT will be conducted in China. 152 eligible participants will be randomly assigned to either an XFZY group or a control group at a 1 : 1 ratio. Participants in the XFZY group will receive XFZY plus routine care, while those in the control group will receive placebo plus routine care. The study period is 26 weeks, including a 2-week run-in period, a 12-week treatment period, and a 12-week follow-up. The primary outcome is the change in visual analogue scale score for angina pain intensity from baseline to 12 weeks. The secondary outcomes are the angina attack frequency and duration, the nitroglycerin dosage consumed, the Canadian Cardiovascular Society grading of effort angina, the Seattle Angina Questionnaire, the EuroQol-5-Dimensions-5-Level, the incidence of major adverse cardiac events, health cost evaluation, and overall assessment for study drugs. Ethics and Dissemination. The study has been approved by the ethics committee of Guangdong Provincial Hospital of Chinese Medicine (approval no. BF2019-175-01). Results will be submitted for publication in peer-reviewed journals and disseminated at scientific conferences. This trial is registered with ChiCTR1900026899, registered on 26 October 2019.