Medical treatment of stable angina: A tailored therapeutic approach

Manolis, Athanasios; Poulimenos, Leonidas; Ambrosio, Giuseppe; Kallistratos, Manolis S.; López‐Sendón, José; Dechend, Ralf; Mancia, Giuseppe; Camm, A. John

doi:10.1016/j.ijcard.2016.06.150

Cited by 39 publications

(24 citation statements)

References 102 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The lack of reliable, objective data is indicated by providing a lower class to the recommendation. The absence of objective data is particularly relevant to the guidelines for antianginal drug therapy [5][6][7][8] . The AHA/ACC 2 , ESC 1 , and NICE 4 recommendations suggest a first-choice therapy with sublingual or short-acting nitroglycerin, β-blockers, and calcium-channel blockers.…”

Section: Guideline Recommendationsmentioning

confidence: 99%

A 'diamond' approach to personalized treatment of angina

et al. 2017

Self Cite

View full text Add to dashboard Cite

Chronic stable angina pectoris is the most prevalent symptomatic manifestation of ischaemic heart disease, and its management is a priority (BOX 1). Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revasculariza tion [1][2][3][4] . However, revascularization by either percutaneous coronary angioplasty or CABG surgery is indicated in patients who have significant artery steno sis (50% left main narrowing or proximal three-vessel disease) to reduce myocardial ischaemia and its adverse clinical manifestation. Antianginal agents are approved by documenting that they improve total exercise duration, together with a reduction in daily frequency of chronic stable angina compared with placebo and/or equivalence to an active comparator. Cardiovascular outcomes, although highly advocated, are not a pre requisite for regulatory approval. None of the antianginal drugs has been proved to reduce cardiovascular mortality or the rate of myocardial infarction. When patients are optimally treated, mortality for chronic stable angina is low, which might explain why all trials designed to improve prognosis have been negative. Guidelines recom mend a first-choice and a second-choice approach, based more on tradition and expert opinion, rather than evidence. This categorical approach has been questioned in the past couple of years 5-8 . Newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than is available for the traditional first-choice drugs. Equally, the often-needed combin ation of double or triple therapy is based on expert opinion and not related to the underlying pathophysio logy. What constitutes optimal antianginal treatment, therefore, varies considerably between countries, and the majority of doctors treat their patients according to their own preconceptions.A group of experts with experience and interest in chronic stable angina met at the University of Ferrara, Italy, to discuss an individualized approach to medical treatment of chronic stable angina, on the basis E X P E RT C O N S E N S U S D O C U M E N TA 'diamond' approach to personalized treatment of angina Abstract | In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for tr...

show abstract

Section: Guideline Recommendationsmentioning

confidence: 99%

A 'diamond' approach to personalized treatment of angina

et al. 2017

Self Cite

View full text Add to dashboard Cite

show abstract

“…In summary, according to ESC guidelines and recently published expert documents, the medical treatment of stable angina has to be individualized taking into account comorbidities and risk factors [2,34,35]. In patients with SCAD and T2DM, the optimal antianginal agent should not only relieve anginal symptoms but also improve the glucose profile.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness and safety of anti-ischemic trimetazidine in patients with stable angina pectoris and Type 2 diabetes

et al. 2017

View full text Add to dashboard Cite

Aim & methods: This 6-month prospective, observational, noninterventional, open-label clinical study assessed the effectiveness/safety of trimetazidine in 737 patients with stable angina pectoris and Type 2 diabetes mellitus (OGYI/51534–1/2014). Results: Trimetazidine-based therapy was effective in stable coronary artery disease, with significant improvements from baseline (p < 0.05) in: number of angina attacks/week (2.9 ± 2.4 vs 1.1 ± 1.6), angina severity (Canadian Cardiovascular Society Classification 1.9 ± 0.8 vs 1.2 ± 0.8), exercise capacity (metabolic equivalents 6.1 ± 1.7 vs 6.5 ± 1.7), and exercise-induced myocardial ischemia (min 5.5 ± 2.5 vs 6.5 ± 2.6). Discussion: Trimetazidine treatment significantly (p < 0.05) improved glucose metabolism, lowered HbA1c (7.1 ± 1.1% vs 6.6 ± 1.0%), glucose levels (7.7 ± 2.1 mmol/l vs 6.9 ± 1.6 mmol/l) and decreased arterial stiffness (pulse wave velocity 11.2 ± 2.1 m/s vs 10.4 ± 2.2 m/s). In most patients, the tolerability of trimetazidine was rated as excellent to good, with a low incidence of adverse events.

show abstract

“…In contrast to the assertion above, one could argue that with respect to the use of LAN, long-term effects on outcomes have never been thoroughly investigated while there are concerns about the development of nitrate tolerance and endothelial dysfunction [9,10]. Moreover their effects on preload and afterload are often partly offset by an increase in heart rate and myocardial contractility resulting by reflex sympathetic activity.…”

Section: Nitrates In Patients With Ccsmentioning

confidence: 97%