Lack of Effect of Nitrates on Exercise Stress Test Results in Patients with Microvascular Angina

Russo, Giulio; Franco, Antonino Di; Lamendola, Priscilla; Tarzia, Pierpaolo; Nerla, Roberto; Stazi, Alessandra; Villano, Angelo; Sestito, Alfonso; Lanza, Gaetano Antonio; Crea, Filippo

doi:10.1007/s10557-013-6439-z

Cited by 84 publications

(45 citation statements)

References 23 publications

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“…If this does not lead to improvement of symptoms additional antianginal drugs should be given (see below). Studies on long acting nitrates have shown no positive effect and are thus not recommended in CMD patients [20]. Although in rare cases they may be effective.…”

Section: Recommendations For Treatmentmentioning

confidence: 99%

Treatment of Angina Pectoris Associated with Coronary Microvascular Dysfunction

Ong

Athanasiadis

Sechtem

2016

Cardiovasc Drugs Ther

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Treatment of angina pectoris associated with coronary microvascular dysfunction is challenging as the underlying mechanisms are often diverse and overlapping. Patients with type 1 coronary microvascular dysfunction (i.e. absence of epicardial coronary artery disease and myocardial disease) should receive strict control of their cardiovascular risk factors and thus receive statins and ACE-inhibitors in most cases. Antianginal medication consists of ß-blockers and/or calcium channel blockers. Second line drugs are ranolazine and nicorandil with limited evidence. Despite individually titrated combinations of these drugs up to 30 % of patients have refractory angina. Rho-kinase inhibitors and endothelin-receptor antagonists represent potential drugs that may prove useful in these patients in the future.

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Section: Recommendations For Treatmentmentioning

confidence: 99%

Treatment of Angina Pectoris Associated with Coronary Microvascular Dysfunction

Ong

Athanasiadis

Sechtem

2016

Cardiovasc Drugs Ther

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“…Among the traditional anti-ischemic drugs, which remain the first-line approach of treatment, long-acting nitrates were evaluated in only 1 single small study, which showed no significant effects in the control of symptoms [5]. Furthermore, the clinical utility of long-acting nitrates in MVA patients can also be questioned by the inconstant efficacy of short-acting nitrates in fully relieving angina attacks [16,17] as well as by the lack of significant effects on ischemic ST segment changes induced by the EST [18,19]. …”

Section: Discussionmentioning

confidence: 99%

Poor Tolerance and Limited Effects of Isosorbide-5-Mononitrate in Microvascular Angina

Villano

Russo

et al. 2015

Cardiology

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Objectives: To assess the effects of isosorbide-5-mononitrate (ISMN) in patients with microvascular angina (MVA). Methods: We randomized 20 MVA patients, treated with a β-blocker or a calcium antagonist, to 60 mg slow-release ISMN (halved to 30 mg if not tolerated) or placebo once a day for 4 weeks; the patients were then switched to the other treatment for another 4 weeks. Their clinical status was assessed with the Seattle Angina Questionnaire (SAQ) and the EuroQoL score for quality of life. The exercise stress test (EST), coronary blood flow (CBF) response to nitrate and the cold pressor test (CPT), brachial artery flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) were also assessed. Results: Nine patients (45%) did not complete the ISMN phase due to side effects; 2 patients refused a follow-up. Nine patients completed the study. The SAQ and EuroQoL scores were significantly better with ISMN than with placebo, although the differences were small. No differences were found between the treatments in the EST results, CBF response to nitroglycerin (p = 0.55) and the CPT (p = 0.54), FMD (p = 0.26) and NMD (p = 0.35). Conclusions: In this study, a high proportion of MVA patients showed an intolerance to ISMN; in those tolerating the drug, significant effects on their angina status were observed, but the benefit appeared to be modest and independent of effects on coronary microvascular function.

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“…[7, 10, 11] Clinical features that may aid in the diagnosis include angina at rest, angina that lingers after cessation of exercise, and angina that does not respond or worsens with short-acting nitrates during exercise or stress testing. [11, 14, 32, 33] In the setting of exertional angina or angina equivalent with normal coronary angiography and no epicardial coronary artery spasm, abnormal myocardial blood flow and/or coronary blood flow are strongly suggestive of microvascular angina.…”

Section: Clinical Featuresmentioning

confidence: 99%

“…They have been associated with improvements in both symptoms and coronary flow reserve in this population. [85] Nitrates are commonly used to relieve angina in coronary artery disease, but they may be less beneficial in microvascular angina[33] as they exert their vasodilatory effects primarily in vessels larger than 200 micrometers. [86] Ranolazine is an alternative anti-anginal agent that has been shown to improve both angina symptoms and coronary flow reserve in microvascular angina.…”

Section: Therapeutic Strategiesmentioning

confidence: 99%

Current Diagnostic and Therapeutic Strategies in Microvascular Angina

Mumma

Flacke²

2014

Curr Emerg Hosp Med Rep

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Microvascular angina is common among patients with signs and symptoms of acute coronary syndrome and is associated with an increased risk of cardiovascular and cerebrovascular events. Unfortunately, microvascular is often under-recognized in clinical settings. The diagnosis of microvascular angina relies on assessment of the functional status of the coronary microvasculature. Invasive strategies include acetylcholine provocation, intracoronary Doppler ultrasound, and intracoronary thermodilution; noninvasive strategies include cardiac positron emission tomography (PET), cardiac magnetic resonance, and Doppler echocardiography. Once the diagnosis of microvascular angina is established, treatment is focused on improving symptoms and reducing future risk of cardiovascular and cerebrovascular events. Pharmacologic options and lifestyle modifications for patients with microvascular angina are similar to those for patients with coronary artery disease.

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Lack of Effect of Nitrates on Exercise Stress Test Results in Patients with Microvascular Angina

Abstract: Short-acting nitrates improve EST results in CAD, but not in MVA patients. In MVA patients a lower nitrate-dependent coronary microvascular dilation may contribute to the lack of effects of nitrates on EST results.

Cited by 84 publications

References 23 publications

Treatment of Angina Pectoris Associated with Coronary Microvascular Dysfunction

Treatment of Angina Pectoris Associated with Coronary Microvascular Dysfunction

Poor Tolerance and Limited Effects of Isosorbide-5-Mononitrate in Microvascular Angina

Current Diagnostic and Therapeutic Strategies in Microvascular Angina

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