Cardioprotective and Antianginal Efficacy of Nicorandil: A Comprehensive Review

ABSTRACT

Angina pectoris remains a significant burden despite advances in medical therapy and coronary revascularization. Many patients (up to 30%) with angina have normal coronary arteries, with coronary microvascular disease and/or coronary artery vasospasm being major drivers of the myocardial demand-supply mismatch. Even among patients revascularized for symptomatic epicardial coronary stenosis, recurrent angina remains highly prevalent. Medical therapy for angina currently centers around 2 disparate goals, viz secondary prevention of hard clinical outcomes and symptom control. Vasodilators, such as nitrates, have been first-line antianginal agents for decades, along with beta-blockers and calcium channel blockers. However, efficacy in symptoms control is heterogenous, depending on underlying mechanism(s) of angina in an individual patient, often necessitating multiple agents. Nicorandil (NCO) is an antianginal agent first discovered in the late 1970s with a uniquely dual mechanism of action. Like a typical nitrate, it mediates medium-large vessel vasodilation through nitric oxide. In addition, NCO has adenosine triphosphate (ATP)-dependent potassium channel agonist activity (K ATP ), mediating microvascular dilatation. Hence, it has proven effective in both coronary artery vasospasm and coronary microvascular disease, typically challenging patient populations. Moreover, emerging evidence suggests that cardiomyocyte protection against ischemia through ischemic preconditioning may be mediated through K ATP agonism. Finally, there is now fairly firm evidence in favor of NCO in terms of hard event reduction among patients with stable coronary artery disease, following myocardial infarction, and perhaps even among patients with congestive heart failure. This review aims to summarize the mechanism of action of NCO, its efficacy as an antianginal, and current evidence behind its impact on hard outcomes. Finally, we review other cardiac and emerging noncardiac indications for NCO use.

A Rare Case of Non-Gestational Ovarian Mixed Intermediate Trophoblastic Tumor Associated with a Mature Cystic Teratoma

Introduction/Objective

Ovarian non-gestational trophoblastic tumors are rare with only a few documented cases. We report a case of a 22-year-old non-sexually active woman who presented to the emergency department with ongoing left lower quadrant abdominal pain. Workup showed elevated Beta-human chorionic gonadotropin levels (152 mIU/mL) and a left ovarian mass. This was initially thought to be an ectopic pregnancy, however patient was non- sexually active. Patient underwent a left oophorectomy and the specimen was sent to pathology.

Methods/Case Report

Microscopic examination of the ovary revealed a mature cystic teratoma with intimately associated foci of loosely cohesive pleomorphic atypical cells. The atypical cells also replaced some of the blood vessel walls and infiltrated the residual ovarian parenchyma. Mitoses were present at (2/10hpf). No necrosis or chorionic villi were identified. Immunohistochemical stains were performed, and the atypical cells were positive for GATA3, inhibin, and human placental lactogen. These cells also showed an elevated ki67 proliferative index (15%). All these findings supported a diagnosis of a placental site trophoblastic tumor. Focally, well-defined cystic structures composed of large epithelioid cells were also noted. These epithelioid cells were positive for GATA3, inhibin, and p63. These cells were negative for human placental lactogen and showed an elevated ki67 proliferative index (12%), findings consistent with an epithelioid trophoblastic tumor component.

Ovarian intermediate trophoblastic tumors are rare and could be of gestational or non-gestational origin. To confirm a non-gestational origin, DNA genotyping was performed. Results showed identical genetic profiles in the teratoma, the intermediate trophoblastic tumor, and in the patient’s benign ovarian tissue. This finding confirmed the diagnosis of a non-gestational mixed intermediate trophoblastic tumor associated with a mature cystic teratoma. This tumor is exceedingly rare with only a few reported cases in literature.

Results (if a Case Study enter NA)

NA

Conclusion

The diagnosis of a non-gestational mixed intermediate trophoblastic tumor is exceedingly rare with only a few reported cases in literature. The combination of immunohistochemistry and dna genotyping confirmed our suspicion and yielded the correct diagnosis.

Low Risk of Hypertrophic Cardiomyopathy With Contemporary Management Strategies Implemented in Non-Referral Regional Community-Based Practices

Major advances in diagnosis and treatment have emerged for hypertrophic cardiomyopathy (HCM), largely in major tertiary referral centers dedicated to this disease. Whether these therapeutic benefits are confined to patients in such highly selected cohorts, or can be implemented effectively in independent regional or community-based populations is not generally appreciated. We assessed management and clinical outcomes in a non-referral HCM center (n = 214 patients) in Eastern Pennsylvania. Over a 6.0 ± 3.2-year follow-up, the HCM-related mortality rate was 0.1% per year attributed to a single disease-related death, in a 49-year-old man with end-stage heart failure, ineligible for heart transplant. Fifteen patients (7%) with prophylactically placed implantable cardioverter-defibrillators (ICDs) experienced appropriate therapy terminating life-threatening ventricular tachyarrhythmias. In 23 other patients (11%; 5%/year), heart failure due to left ventricular outflow obstruction was reversed by surgical septal myectomy (n = 20) or percutaneous alcohol septal ablation (n = 3). This regional HCM cohort was similar to a comparison tertiary center referral population in terms of HCM-mortality: 0.1%/year vs 0.3%/year (p = 0.3) and ICD therapy (31% vs 16% of primary prevention implants), although more frequently with uncomplicated benign clinical course (62% vs 46%; p <0.01). In conclusion, effective contemporary HCM management strategies and outcomes in referral-based HCM centers can be successfully replicated in regional and/or non-referral settings. Therefore, HCM is now a highly treatable disease compatible with normal longevity when assessed in a variety of clinical venues not limited to tertiary centers.

Papillary Squamous Cell Carcinoma of the Cervix: Human Papillomavirus (HPV) Status and Clinicopathologic Features

Introduction/Objective

Papillary squamous cell carcinoma (PSCC) is a rare cervical neoplasm composed of papillae lined by atypical squamous/transitional cells without koilocytosis. It is unclear whether PSCC is related to human papillomavirus (HPV) infection, though rare cases were reportedly associated with HPV type 16. PSCC is thought to be more common in postmenopausal women. Some authors have suggested that PSCC may be understaged due to the prominent exophytic nature of the superficial aspect and relatively deep location of underlying infiltrative nests. It has also been suggested that PSCC has a tendency to recur and/or metastasize late.

Methods

The surgical pathology database of a single large academic institution was searched for squamous cell carcinoma (or squamous cell carcinoma in situ) with papillary features from the cervix, sampled between 1996 and 2018. PCR for human papillomavirus (HPV) L1 protein was run, with sequencing of positive samples.

Results

5 cases diagnosed as “papillary squamous cell carcinoma” were identified. Patient age ranged from 21–63 years (mean 46 years). All tumors showed papillary architecture, often with complex branching and/or fusion. The neoplastic cells had a squamous/transitional appearance with moderate to marked cytologic atypia and at most focal keratinization. Stage ranged from pT1b1 to pT3b (clinical stage IB1 to IVB). HPV L1 PCR was positive in only one case; sequencing confirmed HPV type 16. Upon closer review, the HPV-positive case was from the youngest patient and showed adjacent low-grade squamous intraepithelial lesion (LSIL) as well as focal koilocytic change within the papillary tumor.

Conclusion

Our findings suggest that even in patients with HPV infection, PSCC may be an HPV-independent malignancy. In multiple cases, it was difficult to obtain definitive histologic evidence of invasion prior to resection.