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Volume 10, Supplement 1 - 2009

Volume 10, Supplement 1 - 2009

Table of Contents

Chronic Angina: Definition, Prevalence, and Implications for Quality of Life
Chronic angina is a prevalent manifestation of cardiovascular disease and is mostcommonly due to insufficient oxygen supply from fixed epicardial lesions in the coronaryarteries. In addition to increasing the risk of cardiovascular death and recurrentmyocardial infarction, chronic angina has a significant impact on functional capacityand quality of life. All patients with cardiovascular disease should be closely questionedto determine the functional and symptomatic limitations attributable to ischemicsymptoms. The Canadian Cardiovascular Society Classification of Angina isthe easiest metric to use; however, more sensitive measures such as the Seattle AnginaQuestionnaire offer a better overall assessment of angina symptoms and quality of lifeand can be used to compare the efficacy of different treatments. Treatment strategiesthat begin with either immediate revascularization or optimal medical therapy withantianginal agents significantly improve angina frequency and quality of life. Initialrevascularization, especially with coronary artery bypass grafting, appears to offermore rapid relief of angina compared with percutaneous coronary intervention ormedical therapy in the first months after initial revascularization. After a year offollow-up, though, much of the treatment differences are lost and all strategies(surgical/percutaneous revascularization or medical therapy) result in a significantimprovement of angina symptoms.[Rev Cardiovasc Med. 2009;10(suppl 1):S3-S10 doi: 10.3909/ricm10S10002]
Getting With the ACC/AHA Guidelines for the Treatment of Chronic Angina as a Disease State
The primary objective of treatment in patients with chronic coronary artery disease(CAD) and stable angina is relief of symptoms and improvement of clinical outcome.The American College of Cardiology/American Heart Association guidelines haveemphasized the role of evidence-based therapies. There have been regular updates ofthe guidelines, with an effort to include the latest data in the recommendations. Sincethe 2002 guidelines were published, there have been several pivotal studies that haveprovided strong support for the role of aggressive and optimal medical therapy in improvingclinical outcomes in patients with chronic CAD. Recent data from 2 landmarkstudies have emphasized that optimal medical therapy is as effective as myocardialrevascularization with percutaneous coronary intervention or coronary artery bypassgrafting in reducing risk of adverse clinical outcomes. The 2009-2010 guidelines willlikely incorporate the findings of these studies and accordingly modify the recommendationsfor treatment of patients with chronic CAD and stable angina.[Rev Cardiovasc Med. 2009;10(suppl 1):S11-S20 doi: 10.3909/ricm10S10003]
Evaluating Medical, Percutaneous Coronary Intervention, and Coronary Artery Bypass Surgery Options for Chronic Angina: An Update of the Revised Guidelines
Medical therapy is the standard background treatment for all patients with chronicstable angina. Studies show that antianginal therapies such as late sodium channelblockers (ranolazine), -blockers, calcium channel blockers, and nitrates dispensedalone or in combination can alleviate angina and angina-equivalent symptoms. Forrisk reduction of ischemic events, modification of coronary risk factors with lifestylemodification and medical therapy is the cornerstone. Effective risk modification strategiesinclude lipid management, smoking cessation, diabetes control, weight management,nutritional enhancements, and physical activity. The pursuit of a more definitive treatmentfor chronic angina should be guided by the patient’s clinical presentation, resultsof imaging-based risk-stratification evaluations, response to medical therapies, andpatient preference. Revascularization by percutaneous coronary intervention or coronaryartery bypass surgery may be recommended for patients who have persistent and intolerablesymptoms despite optimal medical therapy and for those who are likely to havea survival benefit from revascularization based on the severity and location of theatherosclerotic lesions.[Rev Cardiovasc Med. 2009;10(suppl 1):S21-S29 doi: 10.3909/ricm10S10004]
Cardiovascular Imaging to Risk-Stratify in Chronic Angina
The location, extent, and severity of obstructive coronary artery disease impactcardiovascular risk and mortality in independent and profound ways. Cardiovascularimaging modalities allow physicians to better define the anatomy and physiology ofcoronary obstructive disease. Conventional coronary angiography remains the mostcommonly used modality to define coronary anatomy. Computed tomography coronaryangiography represents an important innovation, particularly by allowing coronaryanatomy to be assessed in a noninvasive fashion. Stress myocardial perfusion imagingwith single-photon emission computed tomography is a valuable prognostic tool. Stresstesting, echocardiography, and stress myocardial radionuclide perfusion can all playimportant roles in risk stratification. Stress echocardiography is particularly useful inthe clinic, due to the relatively low cost of equipment acquisition and the ability toimage without exposure to radiation. The emerging modality of cardiac positronemission tomography offers the prospect of improved resolution, accurate quantificationof blood flow, and shorter examination times.[Rev Cardiovasc Med. 2009;10(suppl 1):S30-S37 doi: 10.3909/ricm10S10005]
The Antiarrhythmic Effects of Ranolazine
The genesis of cardiac arrhythmia can be grouped into 3 common mechanisms:abnormal automaticity, triggered activity, and re-entry. Alteration of automaticity,triggered activity, conduction, and/or refractoriness of myocardial tissue by drugswill perturb and often prevent the occurrence of arrhythmias. Ranolazine is anovel agent approved in the United States for antianginal therapy. The potentialof ranolazine as an antiarrhythmic drug stems from observation of its abilityto modify multiple ionic currents in cardiac cells responsible for generation ofthe action potential. In contrast to currently available antiarrhythmic drugs,ranolazine is well tolerated and has few side effects. Small clinical trials suggestthat ranolazine may have a role in the treatment of patients with non–STelevationacute coronary syndrome, atrial fibrillation, long QT syndromes,and sinus node dysfunction.[Rev Cardiovasc Med. 2009;10(suppl 1):S38-S45 doi: 10.3909/ricm10S10006]
Potential Application of Late Sodium Current Blockade in the Treatment of Heart Failure and Atrial Fibrillation
The cardiac action potential consists of the sequential activation of various ionchannels in a precisely orchestrated manner. Pathologic alterations of ion channelcurrents disrupt this coordinated behavior and have been linked to arrhythmias, suchas atrial fibrillation, as well as to heart failure. The late sodium current is increasedin the ventricular myocytes in patients with heart failure and can result in contractiledysfunction. The most likely mechanism whereby elevated intracellular Na levels[Rev Cardiovasc Med. 2009;10(suppl 1):S46-S52 doi: 10.3909/ricm10S10007]may lead to heart failure is through calcium overload. Sodium channel blockade isa proven strategy in the treatment of atrial fibrillation. Although all class I antiarrhythmicdrugs inhibit the sodium current, ranolazine has been shown to bea more specific and potent blocker of the late sodium current. In clinical trials,ranolazine has significantly decreased episodes of nonsustained ventriculartachycardia and supraventricular tachycardia as compared with placebo.