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Volume 14, Supplement 1 - 2013

Volume 14, Supplement 1 - 2013

Table of Contents

Stable Ischemic Heart Disease
[Rev Cardiovasc Med. 2013;14(suppl 1):S1-S2 doi: 10.3909/ricm13S1Sintro] © 2013 MedReviews®, LLC
A Contemporary Overview of the Pathophysiology of Angina Pectoris Stable Ischemic Heart Disease
Angina pectoris, a common manifestation of stable ischemic heart disease, is a common problem that continues to grow in our society, given the aging population, the epidemic of obesity, and resultant cardiovascular risk factors. This article focuses on the pathophysiology of this disease, its epidemiology, and the goals of therapy. Although angina pectoris can present in many different ways (eg, typical, atypical, silent), correct identification requires thoughtful assessment and evaluation. It is clear that our focus in the prevention of coronary artery disease by addressing modifiable risk factors is of paramount importance. However, patients often present to physicians because of symptoms and their satisfaction with their care is often dictated by the effectiveness of the treatment for this presentation. It also requires a tailored approach, recognizing that (except in higher-risk scenarios) pharmacologic agents should be the first-line approach to treatment. The availability of newer first-line agents such as ranolazine should allow an effective trial of optimal medical therapy, which, incidentally, forms the cornerstone of many of the appropriateness criteria for revascularization for coronary disease. Coronary revascularization, either by percutaneous coronary intervention or by bypass surgery, is a reasonable option in patients whose symptoms are not adequately controlled with medical therapy alone or in those with high-risk characteristics. Even with revascularization, significant numbers of patients will continue to have (or develop over time) anginal symptoms requiring medical treatment. [ Rev Cardiovasc Med. 2013;14(suppl 1):S3-S10 doi: 10.3909/ ricm13S1S0003] © 2013 MedReviews®, LLC
Current Management of Stable Angina Pectoris Stable Ischemic Heart Disease
Angina is the clinical manifestation of myocardial ischemia and is most often due to coronary stenosis. The management of stable ischemic heart disease requires treatment aimed at both symptom relief and reduction of cardiovascular morbidity and mortality related to atherosclerosis. Risk-factor modification and medical therapy to prevent acute ischemic events and disease progression should be initiated after diagnosis. Patients with symptoms refractory to medical therapy, high-risk stress test results, or anatomic findings have an indication for coronary revascularization. This article addresses evidence that supports the use of secondary prevention therapies and the various antianginal medications that are available for the management of stable angina. [Rev Cardiovasc Med. 2013;14(suppl 1):S11-S22 doi: 10.3909/ricm13S1S0001] © 2013 MedReviews®, LLC
Ranolazine in Stable Angina: Mechanism of Action and Therapeutic Implications Stable Ischemic Heart Disease
Ranolazine, the first member of a newer class of medications, is a piperazine derivative that was first approved by the US Food and Drug Administration in 2006 as a treatment for chronic angina. In 2008, ranolazine received a new indication for the treatment of chronic angina, allowing for its first-line use. Ranolazine’s mechanism of action differs fundamentally from that of currently available anti-ischemic drugs, thus introducing a new paradigm to complement what had been considered conventional therapy. This article outlines this mechanism of action, with a focus on myocardial ischemia and on aspects that may assist in fully exploiting ranolazine’s therapeutic potential. Although the mechanism of action initially postulated to be responsible for ranolazine’s antianginal effect was inhibition of fatty acid oxidation, current evidence suggests alternative explanations. Chief among them is its role as a selective inhibitor of the late component of the Na1 current. The late sodium current has been shown, in several models, to be at the root of a wide spectrum of electrical, contractile, and metabolic derangements.Thus, ranolazine, in addition to its electrophysiologic role, has an influence on cardiomyocyte metabolism, excitation-contraction coupling, and myocardial perfusion. This explains both its efficacy as an antianginal agent and the spectrum of clinical effects observed in human trials, including electrical stabilization and glycemic effects. Accordingly, this article focuses on the current evidence that supports late sodium current inhibition as a plausible mechanism of ranolazine’s therapeutic efficacy. [ Rev Cardiovasc Med. 2013;14(suppl 1):S23-S29 doi: 10.3909/ ricm13S1S0004] © 2013 MedReviews®, LLC
Reasonable Incomplete Revascularization and the Role for Adjunct Medical Therapy in Ischemic Heart Disease Stable Ischemic Heart Disease
The goal of complete revascularization in multivessel coronary artery disease is the elimination of all ischemia-producing lesions, either through coronary artery bypass grafting or percutaneous coronary intervention. However, a substantial proportion of patients receiving contemporary revascularization undergo incomplete revascularization, often with residual ischemia. Currently, the decision of whether to pursue a complete or a limited revascularization strategy is determined by the interventional cardiologist, often in consultation with referring physicians and taking into consideration patient preference. Although there are no guideline-specific recommendations regarding completeness of revascularization, there are passionate arguments supporting the value of complete revascularization by some and the equivalence of incomplete revascularization by others. This article focuses on the evidence that underlies the controversy regarding completeness of revascularization. When interpreting current evidence in patients with multivessel coronary artery disease, decision making regarding treatment strategy should take into account four concepts: (1) incomplete revascularization is more common in clinical practice than complete revascularization; (2) the definition of incomplete revascularization is not uniform; (3) completeness of revascularization is not always superior to incomplete revascularization; and (4) all incomplete revascularization scenarios are not equivalent. We believe that a reasonable incomplete revascularization strategy needs to include a consideration of adjunctive anti-ischemic medications (in particular effective anti-ischemic therapies such as ranolazine), and active monitoring of its effectiveness in reducing residual ischemia. [ Rev Cardiovasc Med. 2013;14(suppl 1):S30-S38 doi: 10.3909/ricm13S1S0005] © 2013 MedReviews®, LLC
Treatment for Chronic Stable Angina: A Guidelines-Based Approach Stable Ischemic Heart Disease
Quality care in clinical cardiology, as in all of medicine, relies on the incorporation of evidence from clinical trials to help inform and drive management of patients. Stable ischemic heart disease (SIHD) presenting with stable angina is a common clinical scenario seen by internists and clinical cardiologists in multiple settings. The management of patients with chronic stable angina requires consideration of risk factors, comorbidities, symptoms, coronary anatomy, and ischemic burden. The physician has a variety of tools at his or her disposal, ranging from lifestyle modification and pharmacotherapy, to percutaneous and surgical procedures. The past two decades have witnessed an explosion in the amount of evidence that is currently available to inform the clinical care of these patients, which has led to the development and dissemination of clinical guidelines that have systematically assessed the different lifestyle, pharmacologic, and revascularization strategies in patients with SIHD. Patients with SIHD demonstrate higher rates of cardiovascular morbidity and mortality and, therefore, their management includes two distinct goals: to mitigate major cardiovascular mortality and morbidity and to reduce symptom burden. This article reviews the intersection of two of these guidelines: the recently published 2012 SIHD guidelines and the Appropriate Use Criteria for Revascularization, first published in 2009 and recently revised in 2012. The overlap between the two guidelines is discussed, as well as the gaps within them, particularly as they relate to the role of pharmacologic therapies, in an effort to build a case for evidence-based management of patients with SIHD. [ Rev Cardiovasc Med. 2013;14(suppl 1):S39-S49 doi: 10.3909/ricmS0002] © 2013 MedReviews®, LLC
Current Management of Stable Angina Pectoris Stable Ischemic Heart Disease
In recent decades, there have been significant advances in both surgical and minimally invasive approaches to revascularization in ischemic heart disease. This article discusses the evidence from key clinical trials comparing the various management strategies in stable coronary artery disease, and culminates in a discussion of the recently published Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial, which randomized patients with type 2 diabetes mellitus and multivessel coronary disease to coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with drug-eluting stents, and found, for the first time, a survival advantage with CABG relative to PCI. [ Rev Cardiovasc Med. 2013;14(suppl 1):S50-S58 doi: 10.3909/ricm13S1S0006] © 2013 MedReviews®, LLC