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The document titled "2024 ESC Guidelines for the management of chronic coronary syndromes" provides comprehensive guidelines for the diagnosis and management of chronic coronary syndromes. It covers various topics such as initial management, diagnostic testing, medical therapy, revascularization options, and treatment for specific patient groups. The guidelines emphasize shared decision-making, patient education, and adherence to healthy lifestyle behaviors. It also highlights the importance of long-term follow-up and care, including strategies to improve medication adherence. These resources can be useful for library patrons conducting research on chronic coronary syndrome and seeking evidence-based guidance on its diagnosis and treatment. [Extracted from the article]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The aim of this study was to test if the current general practice of surgical revascularization is comparable to the setting of International Study of Comparative Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate the comparative risk of cardiovascular events or death after coronary artery bypass grafting. METHODS We selected patients undergoing surgical revascularization and matching ISCHEMIA inclusion criteria. Chronic coronary syndrome patients were included if diagnosis of myocardial ischaemia by functional testing and coronary artery disease at angiography were detected. The primary end point was a composite of cardiovascular death, myocardial infarction, rehospitalization for unstable angina, heart failure and resuscitated cardiac arrest. Secondary end points were death by any cause, cardiovascular death, myocardial infarction and rehospitalization. RESULTS Among 353 patients, the primary outcome occurred in 62 (17.6%) patients. At 6 months, cumulative event-free survival was 97%, at 1 year 96%, at 5 years 89% and at 10 years 80%. Cumulative risk of the primary composite outcome at 5 years was 11%, 18% in the conservative arm of ISCHEMIA and 16% in the revascularization arm of ISCHEMIA (P  < 0.001). Risk of myocardial infarction at 5 years was 7% in surgical patients and 12% and 10% in the conservative and invasive arms of the trial, respectively (P  < 0.001). CONCLUSIONS Long-term results in surgical patients treated for chronic coronary syndromes showed that ISCHEMIA trial findings are not transferable in a 'real-world' scenario and have not changed previous medical practice. A patient-tailored approach, especially with diabetes and reduced left ventricle function, offers the best results in patients with stable coronary artery disease. [ABSTRACT FROM AUTHOR]

Aims  Fractional flow reserve (FFRCT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFRCT would improve economic and clinical outcomes compared with standard care. Methods and results  Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFRCT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFRCT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P  = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P  = 0.01). Conclusion  A strategy of CTCA with selective FFRCT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography. [ABSTRACT FROM AUTHOR]

Persistence or recurrence of angina after a percutaneous coronary intervention (PCI) may affect about 20–40% of patients during short–medium-term follow-up. This appears to be true even when PCI is 'optimized' using physiology-guided approaches and drug-eluting stents. Importantly, persistent or recurrent angina post-PCI is associated with a significant economic burden. Healthcare costs may be almost two-fold higher among patients with persistent or recurrent angina post-PCI vs. those who become symptom-free. However, practice guideline recommendations regarding the management of patients with angina post-PCI are unclear. Gaps in evidence into the mechanisms of post-PCI angina are relevant, and more research seems warranted. The purpose of this document is to review potential mechanisms for the persistence or recurrence of angina post-PCI, propose a practical diagnostic algorithm, and summarize current knowledge gaps. [ABSTRACT FROM AUTHOR]

To assess the use of downstream coronary angiography (ICA) and short-term safety of frontline coronary CT angiography (CTA) with selective CT-derived fractional flow reserve (FFRCT) testing in stable patients with typical angina pectoris. Methods and results: Between 1 January 2016 and 30 June 2016 all patients (N = 774) referred to non-emergent ICA or coronary CTA at Aarhus University Hospital on a suspicion of CAD had frontline CTA performed. Downstream testing and treatment within 3 months and adverse events ≥90 days were registered. Patients were divided into two groups according to the presence of typical angina pectoris, which according to local practice would have resulted in referral to ICA, (low-intermediate-risk, n = 593 [76%]; high-risk, n = 181 [24%]) with mean pre-test probability of CAD of 31 ± 16% and 67 ± 16%, respectively. Coronary CTA was performed in 745 (96%) patients in whom FFRCT was prescribed in 212 (28%) patients. In the high- vs. low-intermediate-risk group, ICA was cancelled in 75% vs. 91%. Coronary revascularization was performed more frequently in high-risk than in low-intermediate-risk patients, 76% vs. 52% (P = 0.03). Mean follow-up time was 157 ± 50 days. Serious clinical events occurred in four patients, but not in any patients with cancelled ICA by coronary CTA with selective FFRCT testing. Conclusion: Frontline coronary CTA with selective FFRCT testing in stable patients with typical angina pectoris in real-world practice is associated with a high rate of safe cancellation of planned ICAs. [ABSTRACT FROM AUTHOR]

The article offers update from the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) on dual antiplatelet therapy in coronary artery disease. Topics discussed are efficacy and safety of dual antiplatelet therapy and risk stratification tools, dual antiplatelet therapy after percutaneous coronary intervention and dual antiplatelet therapy for patients treated with coronary artery bypass and those with medically managed acute coronary syndrome.

Aims Coronary microvascular dysfunction (CMD) can cause angina in the absence of obstructive coronary artery disease (CAD). We studied the frequency and angiographic characteristics of CMD in symptomatic patients with suspected stable CAD and identified CMD as diffusely abnormal coronary vasodilator capacity by positron emission tomography (PET) perfusion imaging. Methods and results We recruited prospectively 189 patients with intermediate pre-test probability of CAD who underwent coronary computed tomography angiography and quantitative 15O-water PET perfusion imaging followed by invasive coronary angiography, and assessment of fractional flow reserve when feasible. Prevalence of obstructive epicardial CAD was 37%. Absolute myocardial blood flow was diffusely reduced (<2.4 mL/g/min) within the left ventricle during adenosine stress in 32 (17%) patients. In 15 (8%) patients, this was explained by three-vessel obstructive CAD, whereas the remaining 17 (9%) were diagnosed with CMD. Of these, 2 (1% of all patients) had no coronary atherosclerosis, 5 (3% of all patients) had non-obstructive atherosclerosis, and in 10 (5% of all patients) CMD coexisted with obstructive CAD. Atypical angina or non-anginal chest pain (53%) was the most common presentation. Older age and male sex were associated with CMD, but other risk factors of CAD were equally common in patients with or without CMD. Conclusion Coronary microvascular dysfunction exists in 9% of symptomatic stable patients with suspected CAD. However, the prevalence of microvascular dysfunction without any coronary atherosclerosis is low (1%) in this population. [ABSTRACT FROM AUTHOR]

Aims CT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS). Methods and results Consecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding > _70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥ 1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98). Conclusion In patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a 'gatekeeper' in this patient cohort, obviating the need for further more expensive tests. [ABSTRACT FROM AUTHOR]

Aims: To examine the 3.5 year prognosis of stable coronary artery disease (CAD) as assessed by coronary computed tomography angiography (CCTA) in real-world clinical practice, overall and within subgroups of patients according to age, sex, and comorbidity. Methods and results: This cohort study included 16,949 patients (median age 57 years; 57% women) with new-onset symptoms suggestive of CAD, who underwent CCTA between January 2008 and December 2012. The endpoint was a composite of late coronary revascularization procedure >90 days after CCTA, myocardial infarction, and all-cause death. The Kaplan-Meier estimator was used to compute 91 day to 3.5 year risk according to the CAD severity. Comparisons between patients with and without CAD were based on Cox-regression adjusted for age, sex, comorbidity, cardiovascular risk factors, concomitant cardiac medications, and post-CCTA treatment within 90 days. The composite endpoint occurred in 486 patients. Risk of the composite endpoint was 1.5% for patients without CAD, 6.8% for obstructive CAD, and 15% for three-vessel/left main disease. Compared with patients without CAD, higher relative risk of the composite endpoint was observed for non-obstructive CAD [hazard ratio (HR): 1.28; 95% confidence interval (CI): 1.01-1.63], obstructive one-vessel CAD (HR: 1.83; 95% CI: 1.37-2.44), two-vessel CAD (HR: 2.97; 95% CI: 2.09-4.22), and three-vessel/left main CAD (HR: 4.41; 95% CI :2.90-6.69). The results were consistent in strata of age, sex, and comorbidity. Conclusion: Coronary artery disease determined by CCTA in real-world practice predicts the 3.5 year composite risk of late revascularization, myocardial infarction, and all-cause death across different groups of age, sex, or comorbidity burden. [ABSTRACT FROM AUTHOR]

Aims Exercise electrocardiography (ExECG) is widely used in suspected stable angina (SA) as the initial test for the evaluation of coronary artery disease (CAD). We hypothesized that exercise stress echo (ESE) would be efficacious with cost advantage over ExECG when utilized as the initial test. Methods and results Consecutive patients with suspected SA, without known CAD were randomized into ExECG or ESE. Patients with positive tests were offered coronary angiography (CA) and with inconclusive tests were referred for further investigations. All patients were followed-up for cardiac events (death, myocardial infarction, and unplanned revascularization). Cost to diagnosis of CAD was calculated by adding the cost of all investigations, up to and including CA. In the 194 and 191 patients in the ExECG vs. ESE groups, respectively, pre-test probability of CAD was similar (34 ± 23 vs. 35 ± 25%, P = 0.6). Results of ExECG were: 108 (55.7%) negative, 14 (7.2%) positive, 72 (37.1%) inconclusive and of ESE were 181 (94.8%) negative, 9 (4.7%) positive, 1 (0.5%) inconclusive, respectively. Patients with obstructive CAD following positive ESE vs. Ex ECG were 9/9 vs. 9/14, respectively (P = 0.04). Cost to diagnosis of CAD was £266 for ESE vs. £327 for ExECG (P = 0.005). Over a mean follow-up period of 21 ± 5 months, event rates were similar between the two groups. Conclusion In this first randomized study, ESE was more efficacious and demonstrated superior cost-saving, compared with ExECG when used as the initial investigation for the evaluation of CAD in patients with new-onset suspected SA without known CAD. [ABSTRACT FROM AUTHOR]

Aims To compare the effectiveness and safety of a cardiac computed tomography (CT) algorithm with functional testing in patients with symptoms suggestive of coronary artery disease (CAD). Methods and results Between April 2011 and July 2013, 350 patients with stable angina, referred to the outpatient clinic of four Dutch hospitals, were prospectively randomized between cardiac CT and functional testing (2 : 1 ratio). The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. By 1 year, fewer patients randomized to cardiac CT reported anginal complaints (P = 0.012). The cumulative radiation dose was slightly higher in the CT group (6.6±8.7 vs. 6.1±9.3 mSv; P < 0.0001). After 1.2 years, event-free survival was 96.7% for patients randomized to CT and 89.8% for patients randomized to functional testing (P = 0.011). After CT, the final diagnosis was established sooner (P < 0.0001), and additional downstream testing was required less frequently (25 vs. 53%, P < 0.0001), resulting in lower cumulative diagnostic costs (€369 vs. €440; P , 0.0001). Conclusion For patients with suspected stable CAD, a tiered cardiac CT protocol offers an effective and safe alternative to functional testing. Incorporating the calcium scan into the diagnostic workup was safe and lowered diagnostic expenses and radiation exposure. [ABSTRACT FROM AUTHOR]

AIMS: This study was designed to determine whether coronary CT angiography (CTA) can detect features of plaque disruption in clinically stable patients and to compare lesion prevalence and features between stable patients and those with acute coronary syndrome (ACS). METHODS: We retrospectively identified patients undergoing CTA, followed by invasive coronary angiography (ICA) within 60 days. Quantitative 3-vessel CTA lesion analysis was performed on all plaques ≥25% stenosis to assess total plaque volume, low attenuation plaque (LAP, <50 HU) volume, and remodelling index. Plaques were qualitatively assessed for CTA features of disruption, including ulceration and intra-plaque dye penetration (IDP). ICA was employed as a reference standard for disruption. A total of 145 (94 ACS and 51 stable) patients were identified. By CTA, plaque disruption was evident in 77.7% of ACS cases. Although more common among those with ACS, CTA also detected plaque disruption in 37.3% of clinically stable patients (P < 0.0001). CONCLUSIONS: Clinically stable patients commonly manifest plaques with features of disruption as determined by CTA. Though the prevalence of plaque disruption is less than patients with ACS, these findings support the concept that some clinically stable patients may harbour 'silent' disrupted plaques. These findings may have implications for detection of 'at risk' plaques and patients. [ABSTRACT FROM AUTHOR]

Aims Chronic ischaemic cardiovascular disease (CICD) is a major cause of mortality and morbidity worldwide. The primary objective of the CICD-Pilot registry was to describe the clinical characteristics and management modalities across Europe in a broad spectrum of patients with CICD. Methods and results The CICD-Pilot registry is an international prospective observational longitudinal registry, conducted in 100 centres from 10 countries selected to reflect the diversity of health systems and care attitudes across Europe. From April 2013 to December 2014, 2420 consecutive CICD patients with non-ST-elevation acute coronary syndrome (n = 755) and chronic stable coronary artery disease (n = 1464), of whom 933 (63.7%) were planned for elective coronary intervention, or with peripheral artery disease (PAD) (n = 201), were enrolled (30.5% female patients). Mean age was 66.6+10.9 years. The following risk factors were reported: smoking 54.6%, diabetes mellitus 29.2%, hypertension 82.6%, and hypercholesterolaemia 74.1%. Assessment of cardiac function was made in 69.5% and an exercise stress test in 21.2% during/within 1 year preceding admission. New stress imaging modalities were applied in a minority of patients. A marked increase was observed at discharge in the rate of prescription of angiotensin-converting enzyme-inhibitors/ angiotensin receptor blockers (82.8%), beta-blockers (80.2%), statins (92.7%), aspirin (90.3%), and clopidogrel (66.8%). Marked differences in clinical profile and treatment modalities were observed across the four cohorts. Conclusion The CICD-Pilot registry suggests that implementation of guideline-recommended therapies has improved since the previous surveys but that important heterogeneity exists in the clinical profile and treatment modalities in the different cohorts of patients enrolled with a broad spectrum of CICDs. [ABSTRACT FROM AUTHOR]

Aims The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial prespecified an analysis to determine whether accounting for recurrent cardiovascular events in addition to first events modified understanding of the treatment effects. Methods and results Patients with stable coronary artery disease (CAD) and moderate or severe ischaemia on stress testing were randomized to either initial invasive (INV) or initial conservative (CON) management. The primary outcome was a composite of cardiovascular death, myocardial infarction (MI), and hospitalization for unstable angina, heart failure, or cardiac arrest. The Ghosh–Lin method was used to estimate mean cumulative incidence of total events with death as a competing risk. The 5179 ISCHEMIA patients experienced 670 index events (318 INV, 352 CON) and 203 recurrent events (102 INV, 101 CON). A single primary event was observed in 9.8% of INV and 10.8% of CON patients while ≥2 primary events were observed in 2.5% and 2.8%, respectively. Patients with recurrent events were older; had more frequent hypertension, diabetes, prior MI, or cerebrovascular disease; and had more multivessel CAD. The average number of primary endpoint events per 100 patients over 4 years was 18.2 in INV [95% confidence interval (CI) 15.8–20.9] and 19.7 in CON (95% CI 17.5–22.2), difference −1.5 (95% CI −5.0 to 2.0, P  = 0.398). Comparable results were obtained when all-cause death was substituted for cardiovascular death and when stroke was added as an event. Conclusions In stable CAD patients with moderate or severe myocardial ischaemia enrolled in ISCHEMIA, an initial INV treatment strategy did not prevent either net recurrent events or net total events more effectively than an initial CON strategy. Clinical trial registration ISCHEMIA ClinicalTrials.gov number, NCT01471522, https://clinicaltrials.gov/ct2/show/NCT01471522. [ABSTRACT FROM AUTHOR]

Coronary artery disease (CAD) is a leading global cause of morbidity and mortality, and improvements in the diagnosis and treatment of CAD can reduce the health and economic burden of this condition. Fractional flow reserve (FFR) is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis. Fractional flow reserve is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal.When compared with standard angiography-guided management, FFR disclosure is impactful on the decision for revascularization and clinical outcomes. In this article, we review recent developments with FFR in patients with stable CAD and recent myocardial infarction. Specifically, we review novel developments in our understanding of CAD pathophysiology, diagnostic applications, prognostic studies, clinical trials, and clinical guidelines. [ABSTRACT FROM AUTHOR]

The article presents the European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EASC) guidelines on myocardial revascularization therapy post-SYNTAX. Featured in the guidelines are the approach to calculate the SYNTAX score and the risk models to assess outcomes as well as the multidisciplinary decision pathways and timing of intervention in coronary artery disease (CAD). Also offered are the recommendations and strategies for diagnosis and treatment of CAD.

Many patients undergoing coronary angiography because of chest pain syndromes, believed to be indicative of obstructive atherosclerosis of the epicardial coronary arteries, are found to have normal angiograms. In the past two decades, a number of studies have reported that abnormalities in the function and structure of the coronary microcirculation may occur in patients without obstructive atherosclerosis, but with risk factors or with myocardial diseases as well as in patients with obstructive atherosclerosis; furthermore, coronary microvascular dysfunction (CMD) can be iatrogenic. In some instances, CMD represents an epiphenomenon, whereas in others it is an important marker of risk or may even contribute to the pathogenesis of cardiovascular and myocardial diseases, thus becoming a therapeutic target. This review article provides an update on the clinical relevance of CMD in different clinical settings and also the implications for therapy. [ABSTRACT FROM PUBLISHER]

Aims The population with stable coronary artery disease (SCAD) is growing but validated models to guide their clinical management are lacking. We developed and validated prognostic models for all-cause mortality and non-fatal myocardial infarction (MI) or coronary death in SCAD. Methods and results Models were developed in a linked electronic health records cohort of 102 023 SCAD patients from the CALIBER programme, with mean follow-up of 4.4 (SD 2.8) years during which 20 817 deaths and 8856 coronary outcomes were observed. The Kaplan–Meier 5-year risk was 20.6% (95% CI, 20.3, 20.9) for mortality and 9.7% (95% CI, 9.4, 9.9) for non-fatal MI or coronary death. The predictors in the models were age, sex, CAD diagnosis, deprivation, smoking, hypertension, diabetes, lipids, heart failure, peripheral arterial disease, atrial fibrillation, stroke, chronic kidney disease, chronic pulmonary disease, liver disease, cancer, depression, anxiety, heart rate, creatinine, white cell count, and haemoglobin. The models had good calibration and discrimination in internal (external) validation with C-index 0.811 (0.735) for all-cause mortality and 0.778 (0.718) for non-fatal MI or coronary death. Using these models to identify patients at high risk (defined by guidelines as 3% annual mortality) and support a management decision associated with hazard ratio 0.8 could save an additional 13–16 life years or 15–18 coronary event-free years per 1000 patients screened, compared with models with just age, sex, and deprivation. Conclusion These validated prognostic models could be used in clinical practice to support risk stratification as recommended in clinical guidelines. [ABSTRACT FROM PUBLISHER]

Aims To evaluate probabilities of disability pension (DP) and premature exit from the workforce (PEW) in patients with stable angina symptoms and no obstructive coronary artery disease (CAD) at angiography compared with obstructive CAD and asymptomatic reference individuals. Methods and results We followed 4303 patients with no prior cardiovascular disease having a first-time coronary angiography (CAG) in 1998–2009 due to stable angina symptoms and 2772 reference individuals from the Copenhagen City Heart Study, all aged <65 years, through registry linkage until 2009 for DP and PEW. Five-year age-adjusted DP-free survival probabilities for reference individuals, patients with angiographically normal coronary arteries, angiographically diffuse non-obstructive CAD, 1 stenotic coronary vessel (1VD), 2VD, and 3VD, respectively, were 0.96, 0.88, 0.84, 0.82, 0.85, and 0.78 in women and 0.98, 0.90, 0.89, 0.89, 0.88, and 0.87 in men. Significant predictors of DP were higher age, angina symptoms, higher body mass index, diabetes, smoking, job status, non-marital status in men, lower income, lower educational level, and co-morbidity. Compared with the reference population, probabilities of DP and PEW were significantly increased in all patients with no gender difference (P > 0.2 for interaction). Thus, in pooled multivariable-adjusted analysis, patients referred to CAG for angina had a three-fold higher probability of DP and ∼50% higher probability of PEW, with little difference between patients with angiographically normal coronary arteries, angiographically diffuse non-obstructive CAD, 1VD, 2VD, 3VD, the hazard ratios for DP being 2.7, 3.0, 3.3, 3.1, and 3.2 (all P < 0.001) and for PEW being 1.3, 1.4, 1.5, 1.6, and 1.6 (all P < 0.05). Conclusion Patients with angina symptoms and angiographically normal coronary arteries, diffuse non-obstructive CAD, or obstructive CAD at angiography have a three-fold increased probability of DP regardless of angiographic findings. [ABSTRACT FROM PUBLISHER]

Percutaneous coronary intervention (PCI) has matured from a pioneering adventure focused on feasibility to a major sub-specialty delivering real clinical results to patients. Despite delivering reductions in mortality and morbidity in the field of acute coronary syndrome and overcoming in-stent restenosis, several challenges still remain. Firstly, we need to adhere to practices supported by established trials: data relating to PCI in stable angina and late reopening of occluded infarct-related vessels suggest that this is not always the case. Secondly, we must develop new trials asking clinically relevant questions in ‘real-world’ populations that are focused on patient-based outcomes. Finally, given the current global financial crisis, it is now more important than ever that we demonstrate cost-effectiveness in our clinical practice. In these turbulent times, we discuss the challenges ahead for PCI in its journey towards evidence-based practice. [ABSTRACT FROM PUBLISHER]

Aims To determine if echocardiographic tissue Doppler imaging (TDI) performed at rest detects reduced myocardial function in patients with reversible ischaemia. Methods and results Eighty-four patients with angina pectoris, no previous history of ischaemic heart disease and normal left ventricular ejection fraction were examined with colour TDI, single-photon emission computed tomography (SPECT), and coronary angiography (CAG). Patients with a normal SPECT (n= 42) constituted the control group and patients with a positive SPECT (n= 42) were divided into patients with (true-positive SPECT, n= 30) or without (false-positive SPECT, n= 12) significant coronary stenoses assessed by CAG. Regional longitudinal systolic (s′), early diastolic (e′), and late diastolic (a′) myocardial velocities were measured by colour TDI at six mitral annular sites and averaged to provide global estimates. In patients with reversible ischaemia both global systolic and diastolic function were impaired in terms of reduced average s′ (5.6 ± 0.9 vs. 6.1 ± 1.1 cm/s; P< 0.05), reduced average e′ (5.9 ± 1.8 vs. 7.0 ± 1.7 cm/s; P< 0.01) and increased average E/e′ (14.2 ± 5.0 vs. 11.5 ± 3.9; P< 0.01). This impairment of the cardiac function was even more evident in patients with a true-positive SPECT with reduced average s′ (5.5 ± 0.8 vs. 6.1 ± 1.1 cm/s; P< 0.01), reduced average e′ (5.2 ± 1.5 vs. 7.0 ± 1.7 cm/s; P< 0.001), and increased average E/e′ (15.5 ± 5.2 vs. 11.5 ± 3.9; P< 0.001), whereas no difference in myocardial velocities could be demonstrated in patients with a false-positive SPECT compared with controls. Conclusion In patients with stable angina pectoris, preserved ejection fraction, and reversible ischaemia assessed by SPECT, echocardiographic colour TDI performed at rest reveals impaired cardiac function. The impairment of the cardiac function seems to be evident only in patients with a true-positive SPECT and colour TDI may therefore increase its diagnostic value. [ABSTRACT FROM PUBLISHER]

Background. Renal insufficiency predisposes to coronary artery disease (CAD), but also CAD and traditional risk factors accelerate renal function loss. Endothelial progenitor cell (EPC) deficiency and elevated asymmetrical dimethyl-l-arginine (ADMA), an endogenous nitric oxide (NO) formation inhibitor, predict adverse CAD outcome. Our aim was to assess changes in estimated glomerular filtration rate over time (ΔeGFR) in relation to baseline EPC blood counts and ADMA levels in stable angina. [ABSTRACT FROM PUBLISHER]

Aims Technological advances in cardiac imaging have led to dramatic increases in test utilization and consumption of a growing proportion of cardiovascular healthcare costs. The opportunity costs of strategies favouring exercise echocardiography or SPECT imaging have been incompletely evaluated. [ABSTRACT FROM PUBLISHER]

Aims Levels of the secreted glycophosphoprotein osteopontin (OPN) have been associated with the presence and extent of coronary artery disease (CAD). The present study assessed the relationship between plasma OPN concentrations and prognosis in patients with chronic stable angina (CSA). [ABSTRACT FROM PUBLISHER]

Aims The Euro Heart Survey of Stable Angina set out to prospectively study the presentation and management of patients with stable angina as first seen by a cardiologist in Europe, with particular reference to adherence to existing guidelines and regional variability in patient presentation and initial assessment. [ABSTRACT FROM PUBLISHER]

Aims In order to assess adherence to guidelines and international variability in management, the Euro Heart Survey of Newly Presenting Angina prospectively studied medical therapy, percutaneous coronary intervention (PCI), and surgery in patients with new-onset stable angina in Europe. [ABSTRACT FROM PUBLISHER]

Background Chronic stable angina is a common condition, but considerable differences exist in the likelihood of acute coronary events such as CHD death, non-fatal myocardial infarction (MI) and unstable angina between individual patients. Effective risk prediction is necessary for optimum management. The aim of this study was to identify clinical features and non-invasive test parameters associated with high risk of these coronary events in stable angina and compose a clinically useful model to predict adverse outcomes in this population.Methods Six hundred and eighty-two patients with stable angina and a positive exercise test (1mm ST depression) from the Total Ischaemic Burden European Trial (TIBET) study, were studied. Resting ECG, exercise tolerance testing and echocardiography were performed at baseline, off anti-anginal therapy. The patients were then randomised to treatment with atenolol, nifedipine or a combination of both. Clinical follow up continued for an average of 2 years (range 1–3 years).Results and conclusions Prior MI or prior CABG were the clinical parameters associated with adverse outcome in patients with stable angina and a positive exercise test. On the ECG, left ventricular hypertrophy was predictive, and on echocardiogram, increased left ventricular dimensions were predictive of adverse events. When combined with time to ischaemia on exercise testing in a simple clinically applicable table these factors could be used to predict of 2 year probability of events for an individual patient. [ABSTRACT FROM PUBLISHER]

Aims: Transmyocardial laser revascularization is a treatment for patients with severe angina pectoris not eligible for conventional revascularization. The effects on myocardial function and reversible ischaemia have not been clarified.Methods and Results: One hundred patients with refractory angina not eligible for conventional revascularization were randomized 1:1 to receive continued optimal medical treatment or transmyocardial revascularization with CO2 laser in addition to medical treatment. Dobutamine stress echocardiography examinations were performed at baseline and at 3 and 12 months after randomization. The effects of transmyocardial revascularization on myocardial function and reversible ischaemia were assessed by visual interpretation of cineloops at rest and during stress in a 16-segment model.After transmyocardial revascularization resting left ventricular wall motion abnormalities increased (P<0·01), whereas wall motion during dobutamine stimulation remained unchanged. The number of probably non-viable segments increased (P<0·01) with a corresponding decrease in the number of ischaemic segments. Fewer patients had the dobutamine infusion discontinued because of chest pain after transmyocardial revascularization with laser, but the chest pain threshold did not increase significantly.Conclusion: Following transmyocardial revascularization, resting wall motion abnormalities worsened, wall motion abnormalities during dobutamine stimulation remained unchanged and the number of probably non-viable segments increased. [ABSTRACT FROM AUTHOR]

It has been reported that medically treated patients with stable angina and positive exercise test for ischaemia have an adverse 1–2 year outlook if they are shown also to have transient, and predominantly silent, ischaemic episodes detected by ambulatory ST segment monitoring during their daily activities: it has been suggested that this investigation could be used to identify patients more likely to benefit from early investigation and treatment. We assessed the long-term (up to 65 months) prognostic significance of transient iscliaemic episodes during daily activities in 172 patients routinely attending cardiac outpatients with medically treated stable angina who had undergone exercise testing and 48 h of ambulatory ST segment monitoring between February 1988 and August 1989 for this purpose. A positive exercise test for ischaemia was not a prerequisite for inclusion. One hundred and four patients (60.5%) had a positive exercise test for iscliaemia and 72 (42%) had transient ischaemia during daily activities (63 had both tests positive). Over a median 50-month follow-up period 54 patients suffered at least one cardiac event (primary event: cardiac death n=7; non-fatal myocardial infarction n=11; unstable angina n=18; elective CABGIPTCA n=18). Two further patients suffered non-cardiac death. Cardiac events, either objective (cardiac death or non-fatal myocardial infarction) or subjective (unstable angina or revascularisation) were no more likely to occur in those with transient ischaemia during daily life when compared with those without, at follow-up times up to 65 months. The detection of transient ischaemia during daily life is of limited practical clinical value in the management of ‘low risk’ medically treated patients with stable angina, and does not appear to help identify subgroups at increased risk of an adverse outcome at follow-up to more than 5 years. [ABSTRACT FROM PUBLISHER]

Safety has been assessed in a total of 1680 subjects who were treated with nicorandil, with 458 patient years of exposure to treatment. Adverse events usually occurred early in the course of treatment. After 30 days of treatment, fewer than 10% of patients reported adverse events. At the recommended doses, the main side effects were limited to headaches. Nearly all episodes of headache were experienced during the first days of nicorandil treatment and were responsible for most of the study withdrawals because of clinical non-acceptability. The incidence can be diminished by a progressive titration.In comparative trials with anti-anginal agents, such as propranolol, diltiazem, nifedipine, ISDN and isosorbide 5 mononitrate, the overall incidence of adverse events was not significantly different between nicorandil and the reference drug. Side-effect distribution was comparable between nicorandil (32%) and diltiazem (30%).Nicorandil can be safely combined with other anti-anginal drugs. Furthermore, due to its favourable pharmacokinetics, nicorandil is less likely to have interactions when combined with another therapeutic agent. Nearly one-third of the patients enrolled in the nicorandil clinical programme were 65 years old or older. Age-specific side-effects were not identified, and overall, the incidence of the most frequent adverse events in the elderly was similar.There is no evidence that nicorandil inducesproarrhythmia, exacerbation of myocardial ischaemia or abrupt withdrawal syndrome. With the progressive titration scheme, no symptomatic decrease in blood pressure was recorded when nicorandil was administered in the range of 10–80 mg . day−1. Heart rate was not significantly affected in the same dose range. Longterm treatment with nicorandil did not induce oedema or weight gain. Nicorandil did not adversely affect the lipidprofile or the glucose level. [ABSTRACT FROM PUBLISHER]

The efficacies and safety of nicorandil, 20 mg b.d., and diltiazem, 60 mg t.d., in the treatment of stable angina pectoris were compared in a double-blind randomized parallel group study involving 123 patients. The duration of the study was 3 months. Exercise tolerance tests were performed by the patients when on placebo (day 0) and at the end of the study period (day 90). Both groups were comparable at day 0 in terms of demography and cardiovascular status. Nicorandil and diltiazemwere both found to decrease the frequency of anginal attacks and the consumption of nitroglycerin tablets (P<0-01). Maximum exercise capacity, the amount of work that could be performed before reaching ischaemic threshold, and the amount of work required to reach onset of angina were significantly increased for both groups of patients on day 90 compared with day 0 (increase in maximum exercise capacity: nicorandil–6.9±18.9 kJ, diltiazem –9.6±16.2 kJ, P = 0.44ns; increase in work to ischaemic threshold: nicorandil–9.4±18.1 kJ, diltiazem–14.7±15.4 kJ, P = 0.10ns; increase in work to onset of angina: nicorandil–100±20.1 kJ, diltiazem–11.4±14.9 kJ, P = 0.68 ns). Differences between the two groups were not significant. The double product of systolic blood pressure × heart rate and peak exercise for both drugs was either unchanged or slightly decreased at ischaemic threshold. Approximately the same number of patients in each group experienced at least one adverse event (nicorandil;–32.7% diltiazem, –30.2%) and an equal number of the patients in each group withdrew from the study because of insufficient efficacy. At the end of the 3 month study it was decided to continue treatment (under double-blind conditions) for 1 year in an equal number of patients in each group (nicorandil, 45%, diltiazem, 43%). This indirectly reflected the investigators judgement of the risk/benefit ratio. These results indicate that the efficacy and safety profile of nicorandil, 20 mg b.d., is comparable with that of diltiazem, 60 mg t.d. [ABSTRACT FROM PUBLISHER]

Acute results and follow-up data over a period of 36 months after attempted PTCA in 406 patients with stable angina and 202 patients with unstable angina are reported. The rate of acute complications (death, myocardial infarction and bypass grafting (CABG) amounted to 1.5% in stable and 6.4% in unstable patients (P< 0.005). Within the first week after PTCA a significantly lower percentage (1.7% vs 10.4%) of cardiac events (death, myocardial infarction, CABG and repeat PTCA) was observed in the stable group (P < 0.001). During a 12-month follow-up period, another 16.3% of the patients in the stable group and 30.7% of unstable patients suffered a new cardiac event (P<0.001). The long-term follow-up of 36 months revealed no significant difference in the event rate between stable and unstable patients (5.4% in both groups). The cumulative rate of myocardial infarction within 3 years after PTCA was significantly lower (3.7% vs 9.4%) in the stable group (P<0.005). The cumulative mortality amounted to 3–0% in stable and 6.4% in unstable patients (P<0.05) and the incidence of repeated PTCA was 8.1% and 19.3% respectively (P <0.001). The crossover rate to CA BG was 10.1% in stable and 17.8% in unstable patients (P <0.01). The total rate of any cardiac event thus amounted to 24.9% in stable and 53. 0% in unstable patients (P<0.001) within a 3-year follow-up period. At the end of follow-up, 74% of the stable patients were asymptomatic, compared with 60% of unstable patients (P<0.01). 45% of the stable group patients and 28%> of the unstable patients were not on antianginal treatment (P<0.01). We conclude that PTCA in unstable angina carries a markedly enhanced risk of acute complications and cardiac events in the early phase after PTCA. In the long run, patients with stable angina have a better quality of life with regard to medical treatment and angina symptoms. [ABSTRACT FROM PUBLISHER]

The efficacy of sustained-release diltiazem (diltiazem-SR) 120 mg b.i.d. was compared with metoprolol 100 mg b.i.d. in 12 patients with stable angina. Following a 1-week placebo period, patients received diltiazem-SR or metoprolol in two 3-week treatment periods, in a randomized double-blind crossover design. Total exercise time was increased more with diltiazem-SR than with metoprolol (1.2 min vs 0.4 min, P=0.02), although the reduction in frequency of weekly anginal attacks was equal with both drugs (5±3 with placebo to 1±1 with both drugs). The difference between diltiazem-SR and metoprolol may, in part, be due to the fact that the tests were performed 12 h after drug administration. The diltiazem plasma levels were in the therapeutic range; metoprolol plasma levels, in contrast, were all below the therapeutic range. In addition, the patients might be tired out earlier during βblockade therapy, because a greater increase in exercise time with diltiazem-SR compared with metoprolol was found in those patients in whom the exercise endpoint changed from angina to fatigue. Thus, diltiazem-SR effectively reduces the frequency of anginal attacks when given twice daily, and improves exercise capacity to a greater extent than metoprolol 12 h after last dose. [ABSTRACT FROM PUBLISHER]

In two randomized, double blind, placebo-controlled, within patient, studies, the effects of 4 doses of a new transdermal therapeutic system containing nitroglycerin (TTS-NTG) were studied in a total of 15 patients with stable exercise-induced angina pectoris. A single 24-hour application of TTS-NTG 10 cm2, TTS-NTG 20 cm2 and TTS placebo (1st study: 6 patients) and of TTS-NTG 40 cm2 TTS-NTG 80 cm2 and TTS placebo (2nd study: 9 patients) was applied on 3 different days, and a symptom-limited cycloergometric exercise test was performed 3, 12 (only in the 2nd study) and 24 hours after the application of each treatment.In comparison with placebo, the doses tested in the 1st study induced, at the 3rd hour post-dosing, a decrease in standing systolic blood pressure and an improvement in exercise tolerance which, however, were not statistically significant while the effects at the 24th hour were similar to those of placebo. In the 2nd study, in comparison with placebo, both TTS-NTG doses induced, 3 hours post-dosing, a significant decrease in both lying and standing systolic (P < 0·01) blood pressure at rest, and a significant (P < 0·01) improvement in exercise tolerance throughout the 24 hours of application.It is concluded that, in patients with exercise-induced angina pectoris due to coronary artery disease, a single application of TTS-NTG 40 cm2 or 80 cm2 results in a 24-hour increase in exercise tolerance. [ABSTRACT FROM PUBLISHER]

The effects of increasing doses ofi.v. nicardipine (2.5, 5.0 and 7.5 or 10.0 mg) on blood pressure, heart rate and exercise performance were studied in 12 patients with chronic effort angina. Plasma nicardipine concentrations correlated closely with the infused doses (r=0.90). Resting haemodynamic changes after nicardipine included a dose-related fall in systolic (5%, 13%, 15%) anddiastolic (0%, 6%, 8%) blood pressure and a rise in heart rate (10%, 19%, 30%). Rate-pressure product was slightly increased after the highest dose (10%). During exercise, maximal systolic blood pressure decreased (3%, 9%, 9%) and heart rate increased (2%, 4%, 9%) but the rate-pressure product remained unchanged. Exercise tolerance improved in 10 patients as indicated by prolonged exercise duration in all, delayed appearance of ST-segment depression in 6, decreased maximal ST-segment depression in 5, and abolished (N = 3) or diminished (N=4) anginal pain at the end of exercise after optimal nicardipine dose. Five of the 10 patients obtained maximum benefit after the highest dose. The other five patients improved after 2.5 or 5.0 mg but deteriorated (N=4) or had no further benefit when the dose was increased (N= 1). One patient deteriorated even after the lowest dose, whereas one patient neither improved nor deteriorated after any dose. The patients who deteriorated after low or high doses tended to be more severely diseased than those who tolerated the maximal dose well. The results stress the importance of individual dose titration of nicardipine to ensure maximum benefit in patients with chronic effort angina. [ABSTRACT FROM PUBLISHER]

The aim of this study was to investigate the effectiveness of ST 567 in patients suffering from ischaemic heart disease and to compare the effects of this drug with those of propranolol. The study group consisted of 48 male patients, mean age 53, with stable, exercise-induced angina pectoris. After a two-week run-in-placebo period, the patients were randomized to treatment with ST 567 3 × 30 mg (N = 24) and propranolol, 3 × 40 mg (TV = 24). The drugs were administered in a double blind fashion during four weeksHeart rate at rest was decreased by ST 567 from 76 to 65 (P < 0.005) by propranolol from 76 to 62 (P < 0.001). Systolic blood pressure was lowered by ST 567 from 131 to 121 (NS) and by propranolol from 133 to 118 (P < 0.05). Exercise tolerance was increased by ST 567 from 20 × 103 to 34 × 103 J (P < 0.05), by propranolol from 26 × 103 to 32 × 103 J (P < 0.01) (mean values). Anginal attacks (no. per week) were reduced by ST 567 from 14 to 7 (P < 0.05) and by propranolol from 14 to 5 (P < 001). Nitroglycerin consumption in no. of tablets per week decreased in ST 567 from 12 to 7 (P < 0.01), in propranolol from 11 to 4 (P < 0.0)There were 7 drop outs during treatment with ST567:2 cases ofmyocardial infarction, exacerbation of angina in 2 patients, visual disturbances in 2 patients, vertigo in 1 patient. With propranolol we observed worsening of angina in 1 patient, with disturbances in sexual potency in 1In conclusion: ST567 is an effective agent in chronic angina but slightly less effective than propranolol in the dosages studied [ABSTRACT FROM PUBLISHER]

Alinidine, a drug which reduces heart rate without depressing myocardial function was compared against metoprolol, a beta-blocking drug, in the treatment of stable angina pectoris in a double-blind cross-over trial. It was found that both drugs reduced anginal attacks and nitroglycerine consumption to a comparable degree. Exercise tolerance did not appear to be improved by either drug yet chest pain at ergometry was postponed by both drugs. In the doses used metoprolol was more effective in restraining heart rate, both at rest and even more during exertion. Both drugs were well tolerated and side-effects werefew. It seems probable that the optimal dose of alinidine was not used in this trial and that the dosage could have been higher [ABSTRACT FROM PUBLISHER]

Work status was studied in 76 male patients under the age of 60, who had been randomly assigned to surgical or medical treatment for coronary artery disease with relatively stable angina (Class I or II NYHA) One year after catheterization or surgery, there were as many patients employed in the medical (84%) as in the surgical (81%) groups, despite a marked improvement of functional symptoms in the latter group; 8% in surgical patients and 11% in medical patients were on social welfare. Surgery did not improve work resumption in patients who had been unemployed for seven months or more before inclusion into the study (71%, versus 67% in medical patients). It is concluded that aorto-coronary bypass surgery cannot be considered as a measure of vocational rehabilitation sufficient to improve employment in patients with mild stable angina, when compared to medical treatment. [ABSTRACT FROM PUBLISHER]

Molsidomine was compared with propranolol for anti-anginal efficacy in a double-blind, cross-over, fixed-dose clinical trial, involving 39 patients with moderate, stable angina pectoris, and objective evidence of coronary sclerosis. The incidence of anginal attacks under molsidomine did not differ statistically from that under propranolol. However, propranolol was more effective in reducing the nitroglycerin requirement at the doses used. Ergometry showed that both drugs increased exercise tolerance to a comparable extent. However the rate pressure product during exertion indicates that these drugs achieve this result via different paths, molsidomine having a nitrate-like effect. Unwanted effects during the four week treatment periods were minor and generally tolerable. Molsidomine is an effective long-acting anti-anginal agent with nitrate-like effects and should be a useful addition to the drugs already in use. [ABSTRACT FROM PUBLISHER]

Verapamil hydrochloride, a calcium antagonist, has been recommended for the treatment of angina pectoris. The effectiveness of 3 × 120 mg verapamil was tested in 33 male patients with stable angina pectoris. The drug reduced the incidence of anginal episodes from 15 (1–98) to two (0–85) in four weeks (median, range); < 0.01. The nitroglycerin consumption was similarly reduced. Exercise tolerance on a bicycle ergometer improved on the average by 10 W( < 0.05). No side effects were observed. It is concluded that verapamil is an effective drug in the treatment of stable angina pectoris. [ABSTRACT FROM PUBLISHER]

The burden of coronary artery disease (CAD) remains high and is the main cause of death and a major cause of morbidity. The treatment of patients with symptomatic CAD is aimed at preventing myocardial infarction and death, and reducing the symptoms of angina and occurrence of myocardial ischaemia. Significant evidence shows that elevated heart rate plays an important role in triggering ischaemic events in patients with CAD and is an important predictor of cardiovascular morbidity and mortality. Ivabradine is a potent anti-anginal agent which works by specifically lowering heart rate. Its antianginal and anti-ischaemic efficacy has been established in a number of randomized placebo-controlled trials, ivabradine being non-inferior to beta-blockers and to calcium antagonists. These trials have also shown that ivabradine is well tolerated and can be safely combined with other cardiovascular agents. The ASSOCIATE study showed that ivabradine provides significant heart rate reduction and improvement in all exercise test criteria in patients with stable angina receiving the beta-blocker atenolol. In addition to its effects on myocardial ischemia and anginal symptoms, ivabradine has the potential to improve clinical outcomes in patients with limiting angina or in patients with a heart rate above 70 b.p.m. as suggested in the BEAUTIFUL trial. In summary, ivabradine is a potent anti-anginal agent, which can be used alone (when beta-blockers are contraindicated or not tolerated) or in combination with beta-blockers, with excellent tolerability. [ABSTRACT FROM PUBLISHER]