Nifedipine Therapy for Coronary-Artery Spasm

Antman, Elliott M.; Muller, James E.; Goldberg, Sheldon; MacAlpin, Rex N.; Rubenfire, Melvyn; Tabatznik, Bernard; Liang, Chang‐seng; Heupler, Fred; Achuff, Stephen C.; Reicher, Nathaniel; Geltman, Edward M.; Kerin, Nicholas Z.; Neff, Raymond K.; Braunwald, Eugene

doi:10.1056/nejm198006053022301

Cited by 413 publications

(77 citation statements)

References 30 publications

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“…Ergonovine can induce irreversible coronary obstruction, resulting in death20 or transmural infarction.21 Myocardial infarction has also been reported as a complication of the cold pressor test. 2 The clinical and angiographic features of the patients with a positive cold pressor test were similar to those of the entire group (table 1). However, these patients were characterized by the ease with which attacks could be provoked by other stimuli; all five had ST elevation at an ergonovine dose of 0.05 mg or less, and four of five had ST elevation or T-wave pseudonormalization with exercise.…”

Section: Methods Patient Populationmentioning

confidence: 54%

Comparative sensitivity of exercise, cold pressor and ergonovine testing in provoking attacks of variant angina in patients with active disease.

et al. 1983

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SUMMARY Exercise, ergonovine and the cold pressor test have been used to provoke variant angina attacks. The sensitivity of these three tests was compared in 34 hospitalized patients with well documented, active variant angina who had recently undergone coronary arteriography. The three tests were usually perfornmed on three consecutive days, and 28 of the 34 Methods Patient PopulationThe following criteria were required for the diagnosis of variant angina: burning or squeezing retrosternal chest pain at rest; relief of pain by sublingual nitroglycerin in less than 5 minutes; ST-segment elevation of at least 0.2 mV not present on the baseline ECG but documented during pain and disappearing after relief of pain; and no evidence of myocardial infarction.The 34 study patients met these criteria, had recently undergone coronary arteriography (table 1) and were hospitalized in the coronary care unit with continuous electrocardiographic monitoring. Except for sublingual nitroglycerin given to relieve angina, the patients were receiving no cardiovascular drugs. Their mean age was 50.5 years (range 32-70 years); 30 were men and four were women. Three had multivessel disease, 16 had a one-vessel stenosis >70% and 15 had no lesions -70%, including three whose coronary arteries appeared normal. Left ventriculography was normal in 29 cases; a hypokinetic or akinetic zone was present in patients 6, 14, 28, 32 and 33. The baseline ECG was normal in 25 cases; patient 1 had minimal ST depression in leads V4 to V6, and eight patients had abnormally negative T waves (patients 5, 8, 11, 15, 25, 28, 32 and 33).The site of ST elevation was the anterior ECG leads in 19 and the inferior leads in 15. The frequency of anginal attacks for each patient during the study period is listed in table 1. Asymptomatic episodes of transient ST elevation occurred in eight patients, all of whom were also experiencing frequent symptomatic attacks. In addition, nearly all patients had brief angina episodes that disappeared spontaneously or with nitroglycerin before electrocardiographic abnormalities could be detected. Both types of attacks were counted.

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Section: Methods Patient Populationmentioning

confidence: 54%

Comparative sensitivity of exercise, cold pressor and ergonovine testing in provoking attacks of variant angina in patients with active disease.

et al. 1983

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“…• All calcium-channel blockers are effective alone or in combination with nitrates in the treatment of vasospastic angina 36 .…”

Section: Key Points For Calcium-channel Blockersmentioning

confidence: 99%

A 'diamond' approach to personalized treatment of angina

et al. 2017

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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...

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“…Nitrates are extremely effective to prevent coronary spasm in patients with variant angina, and calcium antagonists are at present the drugs of choice for long-term treatment of the condition (8)(9)(10). Coronary spasm refractory to these drugs is rare, but can be catastrophic when it occurs with prolonged occlusion of a major coronary artery inducing fatal arrhythmia or hemodynamiccollapse.…”

Section: Discussionmentioning

confidence: 99%

Usefulness of Massive Oral Nicorandil in a Patient with Variant Angina Refractory to Conventional Treatment.

et al. 2003

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A 67-year-old man, who was previously diagnosed with vasospastic angina and treated with standard therapy, was admitted to our hospital because of recurrent chest pain refractory to sublingual nitroglycerin. Admission electrocardiography revealed ST segment elevation in II, III and aVF, and his symptoms were relieved by intravenous bolus administration of nicorandil. He was diagnosed to have active variant angina, and remained symptomatic even after treatment with calcium antagonists and nitrates at optimal doses. Intravenous bolus administration of nicorandil was consistently effective to relieve his symptoms. Anginal attack was finally prevented by massive oral nicorandil in addition to conventional treatment.

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Nifedipine Therapy for Coronary-Artery Spasm

Cited by 413 publications

References 30 publications

Comparative sensitivity of exercise, cold pressor and ergonovine testing in provoking attacks of variant angina in patients with active disease.

Comparative sensitivity of exercise, cold pressor and ergonovine testing in provoking attacks of variant angina in patients with active disease.

A 'diamond' approach to personalized treatment of angina

Usefulness of Massive Oral Nicorandil in a Patient with Variant Angina Refractory to Conventional Treatment.

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