An assessment of the efficacy of a course of using different forms of prolonged-action nitrates in patients with stable stenocardia with the help of repeated daily ECG monitoring

A study was made of the antianginal and anti-ischemic effects of sustac (ST) and trinitrolong (TNL) during their cross continuous use in patients with stable angina pectoris, functional class II-III (according to the classification of the Canadian Association of Cardiologists). In accordance with the daily ECG monitoring data, the three-month treatment with the effective doses of ST and TNL produced a significant lowering of the frequency and the total intensity of the episodes of ST segment depressions of the ischemic type as compared to the continuous administration of placebo. The use of criteria for evaluating the efficacy of the antianginal drugs (the decrease of the total number of ST segment depression episodes during one day by 3 and over and/or reduction of the total intensity of ST segment depression by 50% and over) made it possible to reveal varying effects of the nitrates on painful episodes (PE) and painless episodes of ST segment depression. Both the dosage forms of nitroglycerin administered in the effective amounts (in short- and long-term continuous treatment) significantly lowered the rate and total intensity of myocardial ischemia episodes at the expense of a significant decrease of the frequency and total intensity of PE. They produced no material effect on the number of painless episodes. Provided ST and TNK turned out ineffective, there was a significant rise of the frequency and total intensity of painless episodes in short-term continuous treatment while ST produced the above effect in long-term treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Unstable stenocardia: prognostic significance of painless forms of myocardial ischemia during hospitalization and in the remote period

Variants of unstable angina pectoris were compared upon examination of 366 relevant patients. 24-h ECG monitoring registered painless ST shifts in 75 of them. Treatment at hospital produced results independent of ischemia form (painful or painless). However, the analysis of long-term response for 10 patients demonstrating episodes of ischemia at discharge suggests that in spite of numerous adjustments of treatment in 70% of the patients the risk of unfavorable outcome seems great.     

Ambulatory monitoring of silent myocardial ischemia: what is its utility?

In patients with angina pectoris, ambulatory ST segment monitoring has documented that asymptomatic myocardial ischemic episodes occur with greater frequency than previously suspected. During such episodes, ischemia has been verified by nuclear, echocardiographic, and biochemical techniques. Painless ST segment depression is consistent with severe coronary artery disease when detected by ambulatory monitoring in patients with angina and portends a worsened prognosis in patients about to have vascular surgical procedures. On the other hand, ST depression without angina has a better prognosis than ST depression with angina during treadmill exercise testing. Silent ischemia of prolonged duration per 24-hour period suggests a poor prognosis in patients with a history of unstable angina or myocardial infarction.     

The effect of single doses of antianginal preparations on the correlation of the time of the onset of typical pain and the electrocardiographic signs of myocardial ischemia in patients with stenocardia of effort

Altogether 359 paired bicycle ergometries coupled with administration of single doses of antianginal drugs were carried out in 62 men suffering from angina pectoris of effort, functional classes II and III. A study was made of the indicator characterizing the time that elapsed since the onset of a typical angina pectoris attack till the appearance of the signs of ischemia on the ECG. Administration of effective single doses of antianginal drugs raised the time elapsed since the pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall during the exercise. Administration of ineffective doses of nitrates, calcium antagonists and placebo entailed a decline of that indicator, a rise of the number of cases where the segment ST greater than or equal to 1.0 mm fall was recordable before the onset of painful sensations. Administration of propranolol in ineffective single doses failed to provoke a decrease of the time elapsed since the typical pain onset till the appearance of the ST segment greater than or equal to 1.0 mm fall. Intake of ineffective single doses of nitrates, calcium antagonists and placebo may deprive certain patients of early signalization and appearance of the ECG signs of myocardial ischemia.     

Silent myocardial ischemia: improvement with nisoldipine therapy

Nisoldipine is a new calcium channel blocker of the dihydropyridine family with a high affinity for coronary vessels. We assessed the efficacy of nisoldipine in the treatment of asymptomatic ischemia in 12 patients with chronic, stable angina. Two to four weeks of daily therapy with prn nitroglycerin and placebo was followed by 24-hour ambulatory electrocardiographic recording for ST segment assessment. After two weeks of once-daily nisoldipine, 10 to 20 mg, the ambulatory recording was repeated. A significant difference was seen in ischemia-magnitude products of asymptomatic ischemic episodes in placebo versus active drug periods (P less than .05). When total ischemic burden was considered (ST segment depression during both painless and painful episodes), the difference was even more significant (P less than .02).     

Features of individual pain sensitivity of patients with ischemic heart disease during different variants of bicycle ergometry test

AIM: To assess the significance of individual pain sensitivity in the development of painful and painless episodes of acute myocardial ischemia. MATERIALS AND METHODS: Bicycle ergometry test was carried out in 50 patients aged 35-65 years with angina of effort, functional classes II-III. Before bicycle ergometry, tactile and pain sensitivity thresholds and duration of pain tolerance were assessed by SSM-01 sensometer. RESULTS: Twenty-seven patients showed painful reaction to exercise; 40% of them had a low threshold of pain and 81% poorly tolerated pain. In 11 patients who complained of pain before ECG showed myocardial ischemia, these values were 64 and 91%, respectively. All of 9 patients with painless myocardial ischemia had a high threshold of pain, and 44% of them poorly tolerated pain. CONCLUSION: The data indicate significance of individual pain sensitivity in the development of painless episodes of acute myocardial ischemia.     

Comparative characteristics of stress tests--bicycle ergometry test and psycho-emotional test--in patients with ischemic heart disease

AIM: To compare efficacy bicycle exercise (BE) and psychoemotional tests (PET) in provoking myocardial ischemia and arrhythmia in patients with acute and chronic forms of ischemic heart disease (IHD). MATERIAL AND METHODS: BE and PET (mathematical count test) were performed in 108 IHD patients. 30 patients had stable effort angina (FC II-III), 48 patients had progressing effort angina and 30 patients were at the subacute stage of myocardial infarction. RESULTS: PET was less efficient in detection of myocardial ischemia but is more adequate in detecting episodes of painless ischemia and ventricular rhythm disorders compared to BE. The greatest differences in efficiency of the tests occurred in patients with acute forms of IHD. CONCLUSION: Application of different stress tests in IHD patients raises efficacy of detecting episodes of painful, painless myocardial ischemia and rhythm disorders, specifies mechanisms of coronary failure development.     

Acetylsalicylic acid effects on pain sensitivity to myocardial ischemia and skin sensitivity in patients with angina pectoris

AIM: To clarify if pain-relieving action of acetylsalicylic acid (ASA) is associated with lowered sensitivity of anginal patients to pain due to myocardial ischemia. MATERIALS AND METHODS: A double blind randomized placebo-controlled trial enrolled 10 males aged 42-69 years with stable effort angina (EA) of functional class II-III. When exposed to exercise tolerance test (treadmill, stress-system Sicard 460S, computed ECG), the patients developed EA attack with at least 1 mm decline of ST segment on ECG. The exercise test was made before, 2 and 4 hours after administration of ASA and placebo. Sensitivity to ischemia was estimated by the total depth of the ST segment decline in 11 ECG leads (sigma ST) registered at the attack onset. Tactile and pain thresholds (TT and PT) were studied with a highly reproducible technique. TT and PT were measured before, 2 and 4 hours after ASA and placebo administration. RESULTS: 2 and 4 hours after intake of 100 mg of ASA, sigma ST and TT significantly rose compared to the baseline level and placebo. PT significantly rose vs the baseline level. CONCLUSION: ASA deteriorates sensitivity of anginal patients to myocardial ischemia, skin tactile and pain sensitivity and thus can deprive the EA patient of the pain attack signal. This leads to the risk of overexercising and emergence of painless myocardial ischemia.     

针刺疗法对稳定型心绞痛患者生存质量的影响

目的 :观察针刺治疗对稳定型心绞痛患者生存质量的影响。方法 :6 3例稳定型心绞痛患者随机分为针刺组 32例和对照组 31例。 2组均口服易顺脉胶囊 ,针刺组同时配合针刺治疗 ,并观察治疗前后心电图及生存质量的变化。结果 :2组均治疗 8周后 ,心电图均明显改善 (P <0 .0 1) ,组间比较差异无显著性 (P >0 .0 5 ) ;在改善生存质量方面 ,针刺组明显优于对照组 (P <0 .0 5 )。结论 :针刺治疗能有效改善心肌缺血 ,并能提高患者的生存质量。     

Tl-201 myocardial SPECT in silent myocardial ischemia and angiographically proven coronary heart disease

Silent myocardial ischemia is defined as true myocardial ischemia without angina pectoris in patients with angiographically detected coronary artery disease. In this study 52 patients (46 male, 8 female: mean age 53 years) with a pathological exercise test but no symptoms were investigated. They showed stenosis of 75% or more of the diameter in at least one coronary segment on angiography. Prior to or after catheterization (within 14 days) Tl-201 SPECT was done and evaluated independently of angiography. A clear correlation between angiographically confirmed stenosis and reversible perfusion defects with Tl-201 SPECT was established (62 out of 76 lesions). Furthermore, there was a significant relation between angiographically detected subtotal or total occlusions of coronary vessels and irreversible perfusion defects using Tl-201 SPECT (35 in 44 lesions) (p less than 0.001). In patients with ST depression but without angina pectoris during the exercise test, the Tl-201 SPECT is highly suited to determine the hemodynamic effect of coronary stenoses.     

曲美他嗪对冠心病稳定性劳力型心绞痛患者心肌缺血的影响

目的探讨曲美他嗪对冠心病（CHD）稳定性劳力型心绞痛患者心肌缺血的影响。方法选择在1周内经2次运动试验,结果为阳性且运动持续时间变异低于10％的CHD稳定性劳力型心绞痛患者40例,在原有治疗不变的情况下,加用曲美他唪20mg,3次／d,治疗12周。治疗前后均行平板运动试验,观察用药前后下述指标的变化：①用药前后每周心绞痛发作的次数;②每周硝酸甘油片的用量;③心率及心率与收缩压的乘积;④运动诱发心绞痛发作所需的时间;⑤运动后ST段下降1mm所需的时间;⑥运动持续时间;⑦总工作量。结果曲美他嗪应用12周后,患者每周心绞痛发作次数及硝酸甘油片的用量明显下降（P〈0．05）,而对心率及心率与收缩压的乘积的影响无统计学意义（P〉0．05）。与试验前相比,运动耐量和总工作量显著提高（P〈0．01）,至心绞痛发作的时间及ST段下降1mm所需的时间均明显延长（P〈0．01）。不良反应较少。结论曲美他嗪能增加CHD稳定性劳力型心绞痛患者的运动耐量,改善运动诱发心绞痛的心肌缺血,且安全有效,易于耐受。     

Effects of bisoprolol and isosorbide dinitrate on the circadian distribution of myocardial ischemia

The effects of bisoprolol 10 mg once daily, isosorbide dinitrate (ISDN) 20 mg three times daily, or a combination of these drugs on ischemia during exercise testing and on the occurrence and the circadian variation of ischemia during ambulatory monitoring were evaluated in 23 patients with stable angina pectoris. ISDN and bisoprolol monotherapies both significantly reduced the number of patients with angina pectoris and ST-depression during ergometry while lengthening the time to occurrence of 0.1-mV ST-depression. ISDN did not reduce the number of ischemic episodes measured by Holter monitoring, although it did significantly reduce the duration of ischemia. Bisoprolol monotherapy and combination therapy significantly reduced the number of ischemic episodes as well as the duration of ischemia, total ischemic burden, and number of anginal attacks. The circadian variation of ischemia as measured by Holter monitor was completely abolished by bisoprolol monotherapy and by combination therapy. ISDN monotherapy reduced the evening peak of ischemia but only shortened the morning peak. Both bisoprolol and ISDN reduced ischemia during formal exercise testing, but only bisoprolol effectively reduced the total amount of daily life ischemia as measured by ambulatory monitoring.     

Transcutaneous electrical nerve stimulation (TENS) in angina pectoris

The aim of this study was to determine the efficacy of transcutaneous electrical nerve stimulation (TENS) in the treatment of chronic stable severe angina pectoris. In a short-term study the effect of TENS was studied in 10 male patients with angina pectoris (functional class III and IV). All patients had previously been stabilized on long-term maximal oral treatment. The effects of the treatment were measured by means of repeated bicycle ergometer tests. All patients had an increased working capacity (16-85%), decreased ST segment depression and reduced recovery time during TENS. No adverse effects were observed. A long-term study of TENS on similarly selected patients showed beneficial effects in terms of pain reduction, reduced frequency of anginal attacks, increased physical activity and increased working capacity during bicycle ergometer tests. An invasive study was carried out with respect to systemic and coronary hemodynamics and myocardial metabolism during pacing provoked myocardial ischemia in 13 patients. The results showed that TENS led to an increased tolerance to pacing, improved lactate metabolism, less pronounced ST segment depression. A drop in systolic blood pressure during TENS treatment at identical pacing rates indicated a decreased afterload. An increased coronary flow to ischemic areas in the myocardium was supported by the fact that the rate pressure product during anginal pain increased during TENS.     

运动试验诱发心肌缺血和心绞痛的性别特点研究

目的：观察运动试验诱发男女心肌缺血和心绞痛的特点和差异。方法：将运动试验阳性中出现终止指征没完成次极量的94例患者分为男、女两组，分析其心电图、运动能力、临床症状等，并和部分患者的冠状动脉造影结果对照。结果：男性代谢当量、运动时间明显大于女性（P〈0．05），男性终止症状多见于Bruce2级，女性多见于Bruce1级结束时。ST段下移程度男性高于女性（P〈0．05），下移形态女性水平型多（P〈0．05）、男性近似水平型多（P〈0．05），男性T波倒置多（P〈0．05）。冠状动脉造影结果男性异常率高（78％），女性低（50％）。结论：运动试验对男性心肌缺血和心绞痛的诊断价值较女性大。男性运动试验诱发心肌缺血和心绞痛多发生于Bruce2级。     

Assessment of the effect of nifedipine on myocardial ischaemia by using the ST segment/heart rate slope

Nifedipine is used in patients with stable angina of effort and any resulting change in symptoms is attributed to several effects of nifedipine. However, there have been indications in such patients that one effect of nifedipine could be an increase in the severity of myocardial ischaemia, and the present report involves a trial the results of which could explain this effect. In the present trial, the effect of nifedipine on myocardial ischaemia was assessed by using the maximal ST/heart rate slope. This slope was used as an index of myocardial ischaemia because, in our hands in patients with angina, an increase or a decrease in the value of the slope respectively indicated an increase or a decrease in the severity of myocardial ischaemia as assessed by coronary arteriography. The maximal ST/heart rate slope was obtained at least twice in each of 23 patients with stable angina, with and without nifedipine; two patients were examined twice and three other patients were examined after an increased dose. Nifedipine resulted in an increase in the slope in 24 of the 28 comparisons, no change in three and a decrease in one comparison; there was a statistically significant (P less than 0.005; n = 28; paired t-test) increase in the maximal ST/heart rate slope. A further increase in the slope was obtained by increasing the dose of nifedipine in two out of three patients. The increase in the maximal ST/heart rate slope occurred in the absence of any effect of nifedipine on the initial level of ST segment.(ABSTRACT TRUNCATED AT 250 WORDS)     

The clinical and prognostic information value of painless myocardial ischemia in the early postinfarct period]

A study was made of painless myocardial ischemia in the early postinfarction period (day 14) in order to define its influence on the clinical course and immediate prognosis. 25 patients aged 32 to 60 years with acute primary myocardial infarction were examined. 17 patients had large-focal and 8 small-focal infarction. The patients received diurnal ECG monitoring and physical exercise test on a treadmill. An overwhelming majority of the patients manifested myocardial ischemia not correlating with the rate of angina pectoris attacks. In the patients with small-focal infarction, angina pectoris occurred more frequently and was longer. It has been discovered that the total diurnal duration of transitory myocardial ischemia in the early postinfarction period is a more informative indicator of the immediate prognosis as compared to physical exercise tolerance.     

Mononitrates in therapy of ischemic heart disease polycythemia vera

Effectiveness of Mono Mac was assessed in patients with ischemic heart disease (IHD) and concomitant polycythemia vera (PV). 24-h ECG-monitoring, stress-echoCG were performed in 28 patients aged 35-79 years with painless myocardial ischemia (group 1) and painful form (group 2). Mean dose of Mono Mac was 56.4 mg/day. Clinical response was achieved. Positive changes were observed in decreased number of anginal attacks and nitroglycerin tablets, ST wave depression, number of ischemic episodes, improvement of hemodynamics. It is concluded that Mono Mac has a marked clinical effect in IHD patients having associated polycythemia vera.     

Diagnostic value of late ventricular potentials in patients with painless myocardial ischemia

The study of peculiarities of late ventricular potentials (LVPs) registration in patients with painless myocardial ischemia (PIMI) and painful myocardial ischemia (PMI) in unstable or stable running of ischemic heart disease (IHD) enrolled 113 patients (88 males and 25 females, mean age 52.3 +/- 6.8 years). Follow-up covered 20 +/- 3.2 months. Higher risk was associated with abnormal ECG readings, PlMI, duration of ischemic periods > 70 min for 24 hours, ST depression > 3 mm in heart rate < 100 b/m at the start of the ischemic episodes. Patients with LVPs had PlMI episodes significantly more often. 24-h duration of ischemic episodes and maximal ST depression occurred more frequently in patients with slow fragmental activity. Assessment of Holter ECG monitoring and LVPs allows to ascertain functional status of IHD patients, promotes identification of prognostically unfavourable group of patients at risk of life-threatening arrhythmia and sudden cardiac death.     

不伴心肌梗死的冠状动脉完全闭塞病变心绞痛的临床分析

目的：探讨不伴心肌梗死的冠状动脉完全闭塞病变心绞痛患者的临床特点。方法：对24例不伴心肌梗死的冠状动脉完全闭塞患者的临床表现、心电图、超声心动图及冠状动脉造影资料进行回顾分析。结果：中、高危险组主要表现为静息心绞痛，低危险组和稳定性心绞痛组主要表现为劳力型心绞痛。冠状动脉造影显示左前降支闭塞10例（37％），右冠状动脉闭塞7例（26％），左回旋支闭塞6例（22％），合并多支血管病变23例（95．8％）。心电图ST段异常14例（58．3％）。62．5％的患者进行经皮冠脉血运重建术。结论：不伴心肌梗死的冠状动脉完全闭塞主要表现为劳力型心绞痛，心电图ST段异常是预测冠脉病变严重程度的主要危险因素。经皮冠状动脉介入治疗正成为慢性冠状动脉闭塞的主要手段之一。     

Clinical aspects of trimetazidine (preductal) administration as an antianginal drug

AIM: To study antianginal effectiveness of trimetazidine (TMS) in monotherapy and combined antianginal therapy; to design approaches to prediction of its effect. MATERIAL AND METHODS: An open cross-over randomised trial enrolled 29 anginal patients. They were given a single TMS dose (60 mg) and its effect was compared to that of placebo, propranolol, verapamil, isosorbide dinitrate, nifedipine). The effect was estimated by an increment of bicycle exercise (BE) duration necessary to depress ST segment by 1 mm. 10 patients retained signs of myocardial ischemia at BE though they were treated with specially selected antianginal drugs. In them, we assessed additional benefit of adjuvant TMS. The drugs were tried under acute test and one-month treatment. RESULTS: In acute test a significant antianginal effects of TMS were registered against the placebo. Differences in efficiency of the antianginal drugs were insignificant. The addition of TMS to the selected drugs gave rise to the trend to prolongation of time to ST segment depression by 1 mm. We found a strong correlation between TMS efficiency in acute pharmacological test and in long-term administration. This enables using BE for prediction of long-term effect of the drug. CONCLUSION: TMS has a significant antianginal effect. It is especially beneficial in cases of insufficient effectiveness of conventional antianginal drugs or when their use is problematic because of marked disturbances of hemodynamics.