Comparison of 50-mg and 100-mg sustained-release isosorbide mononitrate in the treatment of stable angina pectoris: effects on quality-of-life indices. Dutch Mononitrate Quality of Life (DUMQOL) Study Group

Vasodilator Therapy: Nitrates and Nicorandil

Nitrates have been used to treat symptoms of chronic stable angina for over 135 years. These drugs are known to activate nitric oxide (NO)-cyclic guanosine-3',-5'-monophasphate (cGMP) signaling pathways underlying vascular smooth muscle cell relaxation, albeit many questions relating to how nitrates work at the cellular level remain unanswered. Physiologically, the anti-angina effects of nitrates are mostly due to peripheral venous dilatation leading to reduction in preload and therefore left ventricular wall stress, and, to a lesser extent, epicardial coronary artery dilatation and lowering of systemic blood pressure. By counteracting ischemic mechanisms, short-acting nitrates offer rapid relief following an angina attack. Long-acting nitrates, used commonly for angina prophylaxis are recommended second-line, after beta-blockers and calcium channel antagonists. Nicorandil is a balanced vasodilator that acts as both NO donor and arterial K(+) ATP channel opener. Nicorandil might also exhibit cardioprotective properties via mitochondrial ischemic preconditioning. While nitrates and nicorandil are effective pharmacological agents for prevention of angina symptoms, when prescribing these drugs it is important to consider that unwanted and poorly tolerated hemodynamic side-effects such as headache and orthostatic hypotension can often occur owing to systemic vasodilatation. It is also necessary to ensure that a dosing regime is followed that avoids nitrate tolerance, which not only results in loss of drug efficacy, but might also cause endothelial dysfunction and increase long-term cardiovascular risk. Here we provide an update on the pharmacological management of chronic stable angina using nitrates and nicorandil.

Chronic Kidney Disease and Health Status Outcomes Following Acute Myocardial Infarction

Background

The association between chronic kidney disease (CKD) and health status outcomes after acute myocardial infarction (AMI) is unknown.

Methods and Results

Patients were enrolled between 2005 and 2008 in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) registry, a prospective multicenter observational study of AMI outcomes. The Seattle Angina Questionnaire and Short Form‐12 were collected at baseline and at 1, 6, and 12 months following AMI. CKD was defined by an estimated glomerular filtration rate <60 mL/min, calculated during the AMI hospitalization. Linear repeated‐measures models assessed the association between CKD and health status after AMI, accounting for the propensity to have follow‐up heath status measures. Of 3617 patients, 576 (16%) had CKD and 3041 (84%) did not have CKD. Patients with CKD were older and had more comorbidity. Patients with CKD were more likely to have multivessel coronary disease and less likely to undergo revascularization. Among AMI survivors, patients with and without CKD had similar health‐related quality of life (adjusted difference of 0.24, 95% CI −1.46 to 1.95), angina frequency (adjusted difference of 1.27, 95% CI −0.05 to 2.58), and mental health (adjusted difference of −0.07, 95% CI −0.90 to 0.75). In contrast, patients with CKD had lower physical health (adjusted difference −1.61, 95% CI −2.49 to −0.74), which was not clinically significant, compared with patients without CKD.

Conclusions

Among AMI survivors, patients with CKD not only had more comorbidities but also, after adjusting for these patient differences, had similar health status compared with patients without CKD. Interventions aimed at improving health status after AMI should not focus on CKD status.