Comparative study of the effect of drug therapy and its combination with hyperbaric oxygenation and hemosorption on stable angina pectoris]

Seventy seven males aged under 60 years with Functional Classes II-IV stable angina were examined. The patients were randomly divided into 3 groups: 1) 24 patients receiving drug therapy alone; 2) 27 patients taking drug therapy in combination with hyperbaric oxygenation; and 3) 26 patients having drug therapy in combination with hemosorption. In all the patient groups, there was a reduction in the frequency of resting and exercise anginal attacks, in Group 3, exercise tolerance was increased due to drug therapy. In a re-examination, there was a significant fall in total cholesterol and high-density lipoprotein cholesterol levels only in Group 3. A comparison of daily drug doses indicated that the functional class improved only due to the adequate antianginal therapy. Thus, hyperbaric oxygenation and hemosorption have no significant action on the degree of stable angina.     

Role of hemorheologic and hemodynamic factors for the efficacy of therapeutic plasmapheresis in patients with ischemic heart disease]

Changes in blood rheological properties and central hemodynamic parameters were studied in patients with Functional Classes III-IV angina pectoris who had undergone therapeutical plasmapheresis. Drastic baseline changes in blood rheological properties, a reduction in myocardial contractility, and high total peripheral vascular resistance (hypokinetic circulation) were found to be indications for plasmapheresis supplemented to antianginal therapy. A positive clinical effect of this therapeutical method may be, to a definite extent, predicted in these patients. The first plasmapheresis procedure improved blood rheology due to the plasma component, making the high baseline levels of fibrinogen and total protein normal, lowered increased platelet aggregation, repeated procedures enhanced the electric superficial charge of red blood cells and the stroke index of the left ventricle.     

Effects of calcium antagonists on the pattern of intracardiac hemodynamics and functional state of the myocardium in patients with angina pectoris relapsing after aortocoronary bypass operation]

The hemodynamic pattern of the antianginal effects of calcium antagonists was examined in 111 patients with Functional Classes II-IV angina pectoris relapsing on an average of 36.7 +/- 1.1 months following aortocoronary bypass surgery, as evidenced by radionuclide ventriculography performed in the acute drug test with finoptin and corinfar. The clinical and functional status improved in 49 patients on finoptin and in 62 on corinfar. In three fourths, the efficacy of finoptin was achieved by decreased myocardial diastolic stiffness and only in a fourth, it was due to lower afterload. In three fourths, the efficacy of corinfar was attained by the action of the vascular component and only in a fourth, it was attributable to its effects on diastolic relaxation--to its direct action on the myocardium.     

Effect of hemosorption on microcirculation, humoral autoimmunity and lipid peroxidation in patients with stable angina pectoris]

Microhemo- and lymphocirculation, capillary permeability, humoral autoimmunity and lipid peroxidation were determined in 46 patients with Functional Classes III-IV stable angina concurrent with multiple atherosclerotic coronary lesions 24 hours following the second hemosorption session. The clinical efficiency of hemosorption was observed in 47.8% of patients with stenotic coronary atherosclerosis refractory to antianginal therapy. In this group of patients, hemosorption led to accelerated microcirculation, increased microcirculatory reserve potentials and decreased microvascular resistance at rest and in reactive postischemic hyperemia. In patients with abnormal humoral autoimmunity and lipid peroxidation, hemosorption resulted in their hormalization.     

Prospective assessment of changes in microcirculation and central hemodynamics in patients with stable angina pectoris according to the data of radionuclide study methods]

The two-year follow-up of 102 patients aged 28-67 years who had Functional Classes I-III stable angina and took no regular antianginal therapy has demonstrated that the first deleterious changes occur in the vasodilator reserve of microcirculation. Then the capillary blood flow velocity decreases, whereas capillary permeability increases. Following 1.5 year of the follow-up there is a dramatic decline in cardiac output, coupled with a significant rise of total peripheral vascular resistance.     

Combined helium-neon laser therapy in patients with ischemic heart disease

The paper describes the combined helium-neon-laser (HNL) therapy (intravenous and topical) developed by the authors to treat patients with coronary heart disease. A high efficacy of this therapy mode was demonstrated in patients over 70 years of age with Functional Classes III-IV angina refractory to antianginal agents. The mechanisms responsible for therapeutic efficiency of laser irradiation were studied at the membraneous and cellular levels. There is evidence that the combined HNL-therapy had advantages over topical HNL exposure in terms of higher clinical efficiency and patterns of abnormal chemical changes.     

State of the coronary arteries and function of the left heart ventricle in patients with ischemic heart disease with silent episodes of myocardial ischemia]

The results of multiviewed coronary angiography with left ventriculography were compared in 36 patients with coronary heart disease concurrent with Functional Classes II-IV stable angina pectoris, who had had frequent episodes of silent myocardial ischemia (SMI), as evidenced by Holter monitoring, and in 23 patients with coronary heart disease in the presence of Functional Classes II-IV stable angina pectoris without SMI episodes. In patients with SMI, the changes in coronary arteries were found to have some features: the extension of an atherosclerotic process (common lesion of all three major arteries), its frequent site in the main trunk of the left coronary artery, high collateralization in the diseased vascular channels, and great extent of stenoses. There were no differences between the groups in the major functional parameters of the left ventricular myocardium.     

Efficacy of fenigidin, senzit and trazikor in the treatment of patients with angina pectoris

One hundred patients with angina pectoris were studied to determine the antianginal effectiveness of senzit, fenigidin and trasicor. The calcium antagonists senzit and fenigidin were found to have high antianginal effect (44% and 78%, respectively) in patients with stable angina pectoris. It was found advisable to use the two drugs in combination with cardiac glycosides in patients with heart failure. A study showed the high antianginal effect of trasicor in postinfarction patients with refractory angina of effort.     

Sanatorium-resort treatment in a low-mountain region of patients with ischemic heart disease after aortocoronary bypass

Sanatorium treatment of patients with coronary heart disease performed in Kislovodsk 6-8 months after aortocoronary bypass leads to a substantial improvement of the functional status of patients without anginal episodes and with Functional Classes I and II angina pectoris.     

Differentiated and individualized approaches to the treatment of patients with angina pectoris at various stages of cardiological care

The paper provides strong evidence for the fact that it is essential to take differential and individual approaches to the treatment of patients with stable angina with due regard for potentialities of their realization at various stages of cardiological care. A method of choosing antianginal agents on an individual basis was proposed, which was suitable for wide application in in- and outpatient settings. It was concluded that this method was comparable with the paired bicycle exercise method, which was based on the examination of 31 patients with Functional Classes II-III angina.     

Effects of prolonged-action nitrates on platelet aggregation and prostaglandin formation]

Platelet aggregation and prostaglandin levels were examined in 50 patients with coronary heart disease concurrent with Functional Classes II-III angina who received nitroglycerin-retard (n = 20; Group 1), corovas (n = 20; Group 2), and placebo (n = 10; Group 3). Long-acting nitrates were found to exert a positive action on thrombocytic hemostasis as decreased platelet aggregation and reverse aggregation in 25% of the corovas-treated patients. Placebo failed to have the same action. Nitroglycerin-retard caused an increase in prostacyclin concentrations. Nitroglycerin-retard and corovas produced a clear-cut antianginal effect. They promoted the reduction in the number of anginal episodes and of nitroglycerin tablets used. No antianginal effect was absent when placebo was used.     

奥扎格雷加灯盏细辛治疗不稳定型心绞痛

目的观察奥扎格雷加灯盏细辛治疗不稳定型心绞痛疗效。方法选择不稳定型心绞痛病人60例，实验组除常规治疗外给予奥扎格雷加灯盏细辛，对照组则加用复方丹参注射液。观察治疗前后临床、心电图、血小板电泳率及血液流变学变化。结果实验组可明显缓解心绞痛及心电图缺血改变，治疗后血小板电泳率显著增快，血液流变学指标改善。结论奥扎格雷加灯盏细辛能有效治疗不稳定型心绞痛。     

Use of bepridil in patients with angina pectoris]

The efficacy of the calcium antagonist bepridil given in a dose of 200-400 mg/day was evaluated in 22 patients with Functional Classes II-III stable angina pectoris. In addition to clinical assessments, repeated bicycle ergometric exercise tests were performed in the patients. The agent was found to be highly potent, well tolerated, and to cause no grave adverse effects.     

Use of plasma sorption in the treatment of hypercholesterolemia in patients with stenocardia

Plasma sorption was performed in patients with Functional Classes III-IV angina pectoris by using the sorbent FAS. A positive clinical effect was achieved in 81%. There was a significant reduction in the levels of total cholesterol and low density lipoprotein cholesterol. The concentration of high density lipoprotein cholesterol remained unchanged.     

Pharmacology and therapeutic effects of nicorandil

Summary Nicorandil, a nicotinamide derivative, is an orally efficacious antianginal drug possessing a nitrate moiety in its chemical structure. This drug is an effective and welltolerated treatment for various types of angina pectoris. Its general efficacy is similar to that of nitrates, with several unique effects on the cardiovascular system. Nicorandil causes sustained dilation of both the arterial resistance and conductive vessels, thus markedly dilating the coronary artery and increasing coronary blood flow. In addition, nicorandil, unlike nitroglycerin or isosorbide dinitrate, possesses little hemodynamic effect on heart rate, blood pressure, or cardiac contractility with clinical doses yielding antianginal effects. The mechanism causing coronary vasodilation has not been completely clarified but appears to be associated partly with increases in c-GMP, as well as the hyperpolarization of the smooth muscle membrane.Nicorandil, in single oral doses of 10–30 mg, has been shown to be effective in chronic stable angina, as assessed objectively by increases in exercise duration and/or the time to onset of ST-segment depression during treadmill exercise. In open studies and controlled efficacy evaluations, nicorandil in daily oral doses of 15–40 mg demonstrated significant effectiveness in the treatment of various types of angina pectoris. Headaches due to vasodilation may occur, and some side effects occurred in 5.1–34% of patients receiving nicorandil, but were generally minor in nature. There was not depressant effect on atrioventricular conduction, which occurs frequently in patients treated with calcium antagonists of the verapamil and diltiazem type. Nicrorandil may be effective even in patients with rest and effort angina who do not respond to combination therapy with calcium antagonists and oral nitrates. Thus, nicorandil appears to be a valuable addition to the arsenal of antianginal drugs due to its low incidence of serious side effects.     

Ranolazine for the treatment of refractory angina in a veterans population

BackgroundPivotal ranolazine trials did not require optimization of conventional medical therapy including coronary revascularization and antianginal drug therapy prior to ranolazine use. This case series describes the use of ranolazine for the treatment of chronic stable angina refractory to maximal medical treatment in a veterans population.ResultsA total of 18 patients with a median age of 66 years were identified. All patients had prior percutaneous coronary intervention and/or coronary artery bypass graft surgery; 83% had three-vessel coronary artery disease, with left main disease present in 39% of patients. Prior to initiating ranolazine, antianginal use consisted of beta blockers (94%), long-acting nitrates (83%) and calcium channel blockers (61%). Median blood pressure (116.2/61.8 mmHg) and pulse (65 beats per min) were controlled. Median preranolazine angina episodes and sublingual nitroglycerin (SLNTG) doses per week were 14 and 10, respectively, with a Canadian Cardiovascular Society (CCS) angina grade of III–IV in 67% of patients. After initiation of ranolazine, median angina episodes per week and SLNTG doses used per week decreased to 0.7 and 0, respectively, with CCS grade of III–IV declining to 17%. Of the 18 subjects enrolled, 44% had complete resolution of angina episodes.ConclusionThe addition of ranolazine to maximally tolerated conventional antianginal drug therapy post coronary revascularization was associated with decreases in angina episodes and SLNTG utilization and improvement in CCS angina grades. Ranolazine may provide an effective treatment option for revascularized patients with refractory angina.     

Management of Stable Angina – Current Guidelines: A Critical Appraisal

Guidelines provide recommendations to improve patient outcomes, but many of the recommendations made for treating patients with stable angina are opinion based rather than evidence based. Risk stratification to predict patients at an increased risk of myocardial infarction (MI) and sudden ischemic death, and selection of patients for possible revascularization, is based on expert opinion. Randomized trials have compared optimal medical therapy to revascularization, after the coronary anatomy was known, and yet routine coronary angiography to exclude left main disease is not recommended. What exactly is optimal antianginal treatment varies considerably from one country’s guideline recommendations to another. None of the antianginal drugs reduce mortality or MI and these drugs are equally effective in treating angina pectoris; and yet beta-blockers and calcium channel blockers are recommended as first line therapy. Double and triple therapy with different classes of antianginal drugs is also expert opinion based rather than evidence based. Recommendations to reduce the incidence of MI and sudden death are appropriate; however the use of a potent, high dose statin, is recommended by AHA/ACC and NICE guidelines for all patients with ischemic heart disease, while the European guidelines recommend a target LDL goal in patients with coronary artery disease (CAD). Management of patients with stable angina pectoris with normal coronary arteries remains ambiguous. This short review critically appraises the recommendations for managing patients with stable angina pectoris.     

Trimetazidine in the treatment of stable angina pectoris TRIADA-(trimetazidine in stable angina twice daily)

The primary objective of the national study TRIADA was to evaluate the efficacy and tolerability of Preductal MR (trimetazidine) at a dose of 35 mg twice daily which was added to current therapy involving the maximum of two antianginal drugs. The outcome was evaluated after 12 weeks of therapy and compared with baseline data. The study included 74 patients with stable exertional angina pectoris (AP) and positive exercise testing results. Trimetazidine (Preductal MR) at a dose of 35 mg twice daily was added to their current therapy involving two drugs at most. TRIADA confirmed that the use of trimetazidine in a new pharmacological form is effective and well tolerated in the treatment of angina pectoris. The study also confirmed a beneficial effect of trimetazidine on the incidence of angina pectoris paroxysms and objective manifestations of ischaemia during exercise testing. Holter monitoring clearly showed that metabolic therapy added to standard antianginal therapy would reduce the incidence of symptomatic and asymptomatic ischaemia. In addition, 12-week therapy with trimetazidine helped improve all end points of quality of life of AP patients evaluated using a questionnaire for AP patients (The Seattle Angina Questionnaire).     

Comparison of the effects of a controlled-release formulation of isosorbide-5-mononitrate and conventional isosorbide dinitrate on exercise performance in men with stable angina pectoris

Thirty-three men with stable exercise-induced angina pectoris entered a randomized, double-blind, crossover study in which controlled-release isosorbide-5-mononitrate 60 mg once daily was compared with conventional isosorbide dinitrate 20 mg 3 times daily. Each drug was given for 2 weeks. Twenty-eight patients completed the study and data on exercise variables are available in 23 patients. Treatment with either drug resulted in significant antianginal effects, when measured 6 hours after a single dose and after 2 weeks of therapy compared with baseline placebo; however, there were significantly fewer signs of myocardial ischemia during treatment with isosorbide-5-mononitrate. There was no evidence of tolerance to either drug treatment but a significant attenuation of resting blood pressure (but not of exercise blood pressure) was observed with both drugs. Headache was the only clinically significant adverse event during therapy and it occurred more frequently in the isosorbide dinitrate treatment group (p less than 0.05 vs placebo); 3 such patients had to withdraw from the study because of headache. Thus, once-daily, controlled-release isosorbide-5-mononitrate appears as effective as conventional isosorbide dinitrate 3 times daily in patients with stable angina pectoris. The once-daily administration is convenient and improves patient compliance.     

Treatment of stable angina.

Severe atherosclerotic narrowing of one or more coronary arteries is responsible for myocardial ischemia and angina pectoris in most patients with stable angina pectoris. The coronary arteries of patients with stable angina also contain many nonobstructive plaques, which are prone to fissures or rupture resulting in presentation of acute coronary syndromes (unstable angina, myocardial infarction, sudden ischemic death). In addition to symptomatic relief of symptoms and an increase in angina-free walking time with antianginal drugs or revascularization procedures, the recent emphasis of treatment has been to reduce adverse clinical outcomes (coronary death and myocardial infarction). The role of smoking cessation, aspirin, treatment of elevated lipids, and treatment of high blood pressure in all patients and of beta-blockers and angiotensin-converting enzyme inhibitors in patients with diminished systolic left ventricular systolic function in reducing adverse outcomes has been well established. What is unknown, however, is whether any anti-anginal drugs (beta-blockers, long-acting nitrates, calcium channel blockers) effect adverse outcomes in patients with stable angina pectoris. Recent trials evaluated the usefulness of suppression of ambulatory ischemia in patients with stable angina pectoris, but it remains to be established whether suppression of ambulatory myocardial ischemia with antianginal agents or revascularization therapy is superior to pharmacologic therapy targeting symptom relief. Patients who have refractory angina despite optimal medical treatment and are not candidates for revascularization procedures may be candidates for newer techniques of transmyocardial revascularization, enhanced external counterpulsation, spinal cord stimulation, or sympathectomy. The usefulness of these techniques, however, needs to be confirmed in large randomized clinical trials.