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Boerhout C, Feenstra R, van de Hoef T, Piek J, Beijk M. Pharmacotherapy in patients with vasomotor disorders. Int J Cardiol Heart Vasc 2023; 48:101267. [PMID: 37727753 PMCID: PMC10505589 DOI: 10.1016/j.ijcha.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/21/2023]
Abstract
Background Anginal symptoms in patients with non-obstructive coronary artery disease are frequently related to vasomotor disorders of the coronary circulation. Although frequently overlooked, a distinct diagnosis of different vasomotor disorders can be made by intracoronary function testing. Early detection and treatment seems beneficial, but little evidence is available for the medical treatment of these disorders. Nevertheless, there are several pharmacotherapeutic options available to treat these patients and improve quality of life. Methods & findings We performed an extensive yet non-systematic literature search to explore available pharmacotherapeutic strategies for addressing vasomotor disorders in individuals experiencing angina and non-obstructive coronary artery disease. This article presents a comprehensive overview of therapeutic possibilities for patients exhibiting abnormal vasoconstriction (such as spasm) and abnormal vasodilation (like coronary microvascular dysfunction). Conclusion Treatment of vasomotor disorders can be very challenging, but a general treatment algorithm based on the existing evidence and the best available current practice is feasible.
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Affiliation(s)
| | | | - T.P. van de Hoef
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J.J. Piek
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
| | - M.A.M. Beijk
- Heart Center, Amsterdam UMC, Amsterdam, the Netherlands
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2
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Boerhout CKM, Beijk MAM, Damman P, Piek JJ, van de Hoef TP. Practical Approach for Angina and Non-Obstructive Coronary Arteries: A State-of-the-Art Review. Korean Circ J 2023; 53:519-534. [PMID: 37525496 PMCID: PMC10435829 DOI: 10.4070/kcj.2023.0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 08/02/2023] Open
Abstract
Anginal symptoms are frequently encountered in patients without the presence of significant obstructive coronary artery disease (CAD). It is increasingly recognized that vasomotor disorders, such as an abnormal vasodilatory capacity of the coronary microcirculation or coronary vasospasm, are the dominant pathophysiological substrate in these patients. Although the evidence with respect to angina in patients with non-obstructive coronary arteries is accumulating, the diagnosis and treatment of these patients remains challenging. In this review, we aimed to provide a comprehensive overview regarding the pathophysiological origins of angina with non-obstructive coronary arteries disorders and its diagnostic and therapeutic considerations. Hereby, we provide a practical approach for the management of patents with angina and non-obstructive CAD.
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Affiliation(s)
| | | | - Peter Damman
- Department of Cardiology, Radboud University Medica Centre, Nijmegen, The Netherlands
| | - Jan J Piek
- Heart Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- Division Heart and Lung, Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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3
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Horváth B, Kovács ZM, Dienes C, Óvári J, Szentandrássy N, Magyar J, Bányász T, Varró A, Nánási PP. Conductance Changes of Na + Channels during the Late Na + Current Flowing under Action Potential Voltage Clamp Conditions in Canine, Rabbit, and Guinea Pig Ventricular Myocytes. Pharmaceuticals (Basel) 2023; 16:ph16040560. [PMID: 37111317 PMCID: PMC10143054 DOI: 10.3390/ph16040560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
Late sodium current (INa,late) is an important inward current contributing to the plateau phase of the action potential (AP) in the mammalian heart. Although INa,late is considered as a possible target for antiarrhythmic agents, several aspects of this current remained hidden. In this work, the profile of INa,late, together with the respective conductance changes (GNa,late), were studied and compared in rabbit, canine, and guinea pig ventricular myocytes using the action potential voltage clamp (APVC) technique. In canine and rabbit myocytes, the density of INa,late was relatively stable during the plateau and decreased only along terminal repolarization of the AP, while GNa,late decreased monotonically. In contrast, INa,late increased monotonically, while GNa,late remained largely unchanged during the AP in guinea pig. The estimated slow inactivation of Na+ channels was much slower in guinea pig than in canine or rabbit myocytes. The characteristics of canine INa,late and GNa,late were not altered by using command APs recorded from rabbit or guinea pig myocytes, indicating that the different shapes of the current profiles are related to genuine interspecies differences in the gating of INa,late. Both INa,late and GNa,late decreased in canine myocytes when the intracellular Ca2+ concentration was reduced either by the extracellular application of 1 µM nisoldipine or by the intracellular application of BAPTA. Finally, a comparison of the INa,late and GNa,late profiles induced by the toxin of Anemonia sulcata (ATX-II) in canine and guinea pig myocytes revealed profound differences between the two species: in dog, the ATX-II induced INa,late and GNa,late showed kinetics similar to those observed with the native current, while in guinea pig, the ATX-II induced GNa,late increased during the AP. Our results show that there are notable interspecies differences in the gating kinetics of INa,late that cannot be explained by differences in AP morphology. These differences must be considered when interpreting the INa,late results obtained in guinea pig.
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Affiliation(s)
- Balázs Horváth
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Zsigmond M Kovács
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Csaba Dienes
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - József Óvári
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Norbert Szentandrássy
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Department of Basic Medical Sciences, Faculty of Dentistry, University of Debrecen, 4032 Debrecen, Hungary
| | - János Magyar
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Division of Sport Physiology, Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Bányász
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - András Varró
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Péter P Nánási
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Department of Dental Physiology and Pharmacology, Faculty of Dentistry, University of Debrecen, 4032 Debrecen, Hungary
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4
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McChord J, Ong P. Use of pharmacology in the diagnosis and management of vasomotor and microcirculation disorders. Heart 2023; 109:643-649. [PMID: 36657963 DOI: 10.1136/heartjnl-2022-321267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Johanna McChord
- Department of Cardiology, Robert-Bosch-Krankenhaus GmbH, Stuttgart, Germany
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus GmbH, Stuttgart, Germany
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5
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Parvand M, Cai L, Ghadiri S, Humphries KH, Starovoytov A, Daniele P, Prodan-bhalla N, Sedlak TL. One-Year Prospective Follow-up of Women With INOCA and MINOCA at a Canadian Women’s Heart Centre. Can J Cardiol 2022. [DOI: 10.1016/j.cjca.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022] Open
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Yang Z, Lin S, Liu Y, Ren Q, Ge Z, Wang C, Bi Y, Wang X, Mao J. Traditional chinese medicine in coronary microvascular disease. Front Pharmacol 2022; 13:929159. [PMID: 36003524 PMCID: PMC9393228 DOI: 10.3389/fphar.2022.929159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary microvascular disease (CMVD) is common in patients with cardiovascular risk factors and is associated with an increased risk of adverse cardiovascular events. Although the study of CMVD in modern medicine is ongoing, there is still no effective treatment for it. Traditional Chinese medicine (TCM) has some clinical advantages based on syndrome differentiation and individualized treatment. In this review, we review the clinical significance, pathogenesis, and current treatments of CMVD and systematically summarize the clinical efficacy and potential action mechanisms of TCM for CMVD. In addition, the scientific problems that need to be solved urgently and the research strategy of TCM for CMVD are described. CMVD has great clinical significance, but there are still many gaps in the related research. This review aims to attract the attention of clinicians to CMVD and promote research on CMVD in TCM.
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Affiliation(s)
- Zhihua Yang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shanshan Lin
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yangxi Liu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Qiuan Ren
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhao Ge
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ci Wang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yingfei Bi
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xianliang Wang
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jingyuan Mao
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
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Dong T, Zhao Y, Jin HF, Shen L, Lin Y, Si LL, Chen L, Liu JC. SNTA1-deficient human cardiomyocytes demonstrate hypertrophic phenotype and calcium handling disorder. Stem Cell Res Ther 2022; 13:288. [PMID: 35773684 PMCID: PMC9248201 DOI: 10.1186/s13287-022-02955-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background α-1-syntrophin (SNTA1), a protein encoded by SNTA1, is highly expressed in human cardiomyocytes. Mutations in SNTA1 are associated with arrhythmia and cardiomyopathy. Previous research on SNTA1 has been based on non-human cardiomyocytes. This study was designed to identify the phenotype of SNTA1-deficiency using human cardiomyocytes. Methods SNTA1 was knocked out in the H9 embryonic stem cell line using the CRISPR-Cas9 system. H9SNTA1KO cells were then induced to differentiate into cardiomyocytes using small molecule inhibitors. The phenotypic discrepancies associated with SNTA1-deficient cardiomyocytes were investigated. Results SNTA1 was truncated at the 149th amino acid position of PH1 domain by a stop codon (TGA) using the CRISPR-Cas9 system. SNTA1-deficiency did not affect the pluripotency of H9SNTA1KO, and they retain their in vitro ability to differentiate into cardiomyocytes. However, H9SNTA1KO derived cardiomyocytes exhibited hypertrophic phenotype, lower cardiac contractility, weak calcium transient intensity, and lower level of calcium in the sarcoplasmic reticulum. Early treatment of SNTA1-deficient cardiomyocytes with ranolazine improved the calcium transient intensity and cardiac contractility. Conclusion SNTA1-deficient cardiomyocytes can be used to research the etiology, pathogenesis, and potential therapies for myocardial diseases. The SNTA1-deficient cardiomyocyte model suggests that the maintenance of cardiac calcium homeostasis is a key target in the treatment of myocardial-related diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-022-02955-4.
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Affiliation(s)
- Tao Dong
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China.
| | - Yan Zhao
- College of Life Science and Agroforestry, Qiqihar University, Qiqihar, 161006, Heilongjiang, China
| | - Hai-Feng Jin
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China
| | - Lei Shen
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China
| | - Yan Lin
- Basic Medicine School, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China
| | - Long-Long Si
- CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Li Chen
- CAS Key Laboratory of Quantitative Engineering Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Ji-Cheng Liu
- Qiqihar Institute of Medical and Pharmaceutical Sciences, Qiqihar Medical University, 333 Bukui Street, Qiqihar, 161006, Heilongjiang, China.
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8
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Jiang Y, Li X, Guo T, Lu WJ, Ma S, Chang Y, Song Y, Zhang S, Bai R, Wang H, Qi M, Jiang H, Zhang H, Lan F. Ranolazine rescues the heart failure phenotype of PLN-deficient human pluripotent stem cell-derived cardiomyocytes. Stem Cell Reports 2022; 17:804-819. [PMID: 35334215 PMCID: PMC9023809 DOI: 10.1016/j.stemcr.2022.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/28/2022] Open
Abstract
Phospholamban (PLN) is a key regulator that controls the function of the sarcoplasmic reticulum (SR) and is required for the regulation of cardiac contractile function. Although PLN-deficient mice demonstrated improved cardiac function, PLN loss in humans can result in dilated cardiomyopathy (DCM) or heart failure (HF). The CRISPR-Cas9 technology was used to create a PLN knockout human induced pluripotent stem cell (hiPSC) line in this study. PLN deletion hiPSCs-CMs had enhanced contractility at day 30, but proceeded to a cardiac failure phenotype at day 60, with decreased contractility, mitochondrial damage, increased ROS production, cellular energy metabolism imbalance, and poor Ca2+ handling. Furthermore, adding ranolazine to PLN knockout hiPSCs-CMs at day 60 can partially restore Ca2+ handling disorders and cellular energy metabolism, alleviating the PLN knockout phenotype of HF, implying that the disorder of intracellular Ca2+ transport and the imbalance of cellular energy metabolism are the primary mechanisms for PLN deficiency pathogenesis.
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Affiliation(s)
- Youxu Jiang
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Xiaowei Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Tianwei Guo
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Wen-Jing Lu
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Shuhong Ma
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Yun Chang
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China; Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Yuanxiu Song
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Siyao Zhang
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Rui Bai
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Hongyue Wang
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Man Qi
- Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, Shenzhen Key Laboratory of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Key Laboratory of Pluripotent Stem Cells in Cardiac Repair and Regeneration, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Hongfeng Jiang
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China.
| | - Hongjia Zhang
- Beijing Laboratory for Cardiovascular Precision Medicine, MOE Key Laboratory of Biomedical Engineering for Cardiovascular Disease Research, Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China.
| | - Feng Lan
- Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, Shenzhen Key Laboratory of Cardiovascular Disease, State Key Laboratory of Cardiovascular Disease, Key Laboratory of Pluripotent Stem Cells in Cardiac Repair and Regeneration, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.
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9
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Zhu Y, Zhang H, Ma S, Miao L, Jin G, Li J, Nuerkaman T, Sun Q, Liu Y, Yin S. Stereoselective quantitative analysis of ranolazine in plasma and tissue samples: application in pharmacokinetics and tissue distribution studies. NEW J CHEM 2022. [DOI: 10.1039/d2nj02302d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This study aimed to develop a rapid and sensitive reversed-phase mode high-performance liquid chromatography-electrospray ionization coupled with a tandem mass spectrometry method for the simultaneous determination of ranolazine enantiomers in rat plasma and tissues.
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Affiliation(s)
- Yuanyuan Zhu
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning, 110016, China
| | - Hong Zhang
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, No. 103 Wenhua Road, Shenyang 110016, China
| | - Siman Ma
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning, 110016, China
| | - Lizhi Miao
- Safety Evaluation Center of Shenyang SYRICI Testing Co., Ltd., Shenyang 110141, China
| | - Ge Jin
- School of Pharmacy, Shenyang Medical College, No. 146 Huanghe North Street, Shenyang, Liaoning, 110034, China
| | - Jiahui Li
- School of Business Administration, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Tohutanguli Nuerkaman
- School of Business Administration, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Qiruo Sun
- School of Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning, 110016, China
| | - Yang Liu
- School of Pharmacy, Shenyang Medical College, No. 146 Huanghe North Street, Shenyang, Liaoning, 110034, China
| | - Shiliang Yin
- School of Pharmacy, Shenyang Medical College, No. 146 Huanghe North Street, Shenyang, Liaoning, 110034, China
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Abstract
Coronary microvascular dysfunction (CMD) is defined as a mismatch of myocardial blood supply and oxygen consumption due to a dysfunction of the coronary microvessels. Up to 20-30% of patients with CMD have progressive worsening of symptoms with significant impairment of quality of life. Large-scale randomized studies of the pharmacologic treatment of CMD are lacking. Classic anti-ischemic drugs are the initial form of treatment, but efficacy is often limited. Ranolazine has a unique mechanism of action that does not affect blood pressure or heart rate. When added to existing anti-anginal agents, ranolazine improved at least one domain in eight of ten studies in which a questionnaire was used to assess patient health status. Five studies evaluated coronary arterial flow reserve (CFR), reporting that patients with low values had significant improvement in CFR and suggesting that those with more severe CMD respond more favorably to ranolazine. In two studies, exercise duration and time to myocardial ischemia were significantly increased after treatment with ranolazine. Data are lacking for ranolazine use as the sole agent for CMD treatment. Some questions remain to be answered regarding ranolazine use for CMD. Larger studies of longer duration are needed to verify the effectiveness of ranolazine in the treatment of CMD.
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Affiliation(s)
- Randall P Sharp
- Department of Pharmacy Practice c/o Heart Solutions of Oklahoma, College of Pharmacy, Southwestern Oklahoma State University, 10413 Greenbriar Parkway, Oklahoma City, OK, 73159, USA.
| | - Edna Patatanian
- College of Pharmacy, Southwestern Oklahoma State University, 100 Campus Drive, Weatherford, OK, 73096, USA
| | - Riaz Sirajuddin
- Heart Solutions of Oklahoma, 10413 Greenbriar Parkway, Oklahoma City, OK, 73159, USA
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Kunadian V, Chieffo A, Camici PG, Berry C, Escaned J, Maas AHEM, Prescott E, Karam N, Appelman Y, Fraccaro C, Louise Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott JD, Badimon L, Duncker DJ, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. Eur Heart J 2021; 41:3504-3520. [PMID: 32626906 DOI: 10.1093/eurheartj/ehaa503] [Citation(s) in RCA: 352] [Impact Index Per Article: 117.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/17/2022] Open
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, M4:146 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
| | | | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | | | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.,Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - J Dawn Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk J Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. 'Policlinico-Vittorio Emanuele', University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK.,Yale University School of Medicine, New Haven, CT, USA
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Kunadian V, Chieffo A, Camici P, Berry C, Escaned J, Maas A, Prescott E, Karam N, Appelman Y, Fraccaro C, Buchanan G, Manzo-Silberman S, Al-Lamee R, Regar E, Lansky A, Abbott J, Badimon L, Duncker D, Mehran R, Capodanno D, Baumbach A. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. EUROINTERVENTION 2021; 16:1049-1069. [PMID: 32624456 PMCID: PMC9707543 DOI: 10.4244/eijy20m07_01] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/01/2020] [Indexed: 11/23/2022]
Abstract
This consensus document, a summary of the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), appraises the importance of ischaemia with non-obstructive coronary arteries (INOCA). Angina pectoris affects approximately 112 million people globally. Up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease, more common in women than in men, and a large proportion have INOCA as a cause of their symptoms. INOCA patients present with a wide spectrum of symptoms and signs that are often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. INOCA can result from heterogeneous mechanism including coronary vasospasm and microvascular dysfunction and is not a benign condition. Compared to asymptomatic individuals, INOCA is associated with increased incidence of cardiovascular events, repeated hospital admissions, as well as impaired quality of life and associated increased health care costs. This consensus document provides a definition of INOCA and guidance to the community on the diagnostic approach and management of INOCA based on existing evidence from research and best available clinical practice; noting gaps in knowledge and potential areas for further investigation.
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Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Paolo Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Angela Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Nicole Karam
- European Hospital Georges Pompidou (Cardiology Department), Paris University and Paris Cardiovascular Research Center (INSERMU970), Paris, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location VU University Medical Center, Amsterdam, the Netherlands
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Padova, Italy
| | - Gill Buchanan
- North Cumbria Integrated Care NHS Foundation Trust, Cumbria, United Kingdom
| | | | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Bart’s Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - J. Abbott
- Lifespan Cardiovascular Institute and Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Barcelona, Spain
| | - Dirk Duncker
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Davide Capodanno
- CardioThoracic-Vascular and Transplant Department, A.O.U. ‘Policlinico-Vittorio Emanuele’, University of Catania, Catania, Italy
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
- Yale University School of Medicine, New Haven, CT, USA
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Kofler T, Hess S, Moccetti F, Pepine CJ, Attinger A, Wolfrum M, Toggweiler S, Kobza R, Cuculi F, Bossard M. Efficacy of Ranolazine for Treatment of Coronary Microvascular Dysfunction-A Systematic Review and Meta-analysis of Randomized Trials. CJC Open 2021; 3:101-108. [PMID: 33458636 PMCID: PMC7801206 DOI: 10.1016/j.cjco.2020.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022] Open
Abstract
Background Coronary microvascular dysfunction (CMD) is a common cause of angina and exercise intolerance in patients without obstructive coronary artery disease. The efficacy of ranolazine, a late sodium channel blocker, in patients with symptomatic obstructive coronary artery disease is well established. To evaluate the efficacy of ranolazine in CMD, we performed a systematic review and meta-analysis of randomized studies. Methods MEDLINE, EMBASE, Cochrane CENTRAL, and conference abstracts were searched from January 1975 to March 2020. Randomized trials evaluating ranolazine in patients with CMD were screened. Two reviewers independently extracted data and assessed study quality. End points of interest included a change in angina measured by the Seattle Angina Questionnaire (SAQ), coronary flow reserve (CFR), and clinical outcomes. Data were combined using random-effects models. Results Of 836 citations, 6 randomized studies (318 patients) were included. Median follow-up was 4 weeks. When pooling the 6 trials analyzing ranolazine, we found that patients treated with ranolazine had a higher SAQ value regarding physical functioning (mean difference, 6.42; 95% confidence interval [CI], 2.41; 10.42) quality of life (10.07; 95% CI, 3.4; 16.74), and angina stability (20.14; 95% CI, 10.12; 30.17), as well as improved CFR (0.27; 95% CI, 0.09; 0.45) compared with placebo/control therapy. A high heterogeneity was observed (range I2, 30%-84%). Conclusions In CMD, ranolazine may be associated with improvements in CFR and some of the SAQ domains, including angina stability, physical functioning, and quality of life. However, it does not seem to beneficially impact angina frequency and treatment satisfaction. It is also unknown if it improves prognosis of afflicted patients.
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Affiliation(s)
- Thomas Kofler
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Stefanie Hess
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Federico Moccetti
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Adrian Attinger
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Mathias Wolfrum
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Stefan Toggweiler
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
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Rayner-Hartley E, Parvand M, Humphries KH, Starovoytov A, Park JE, Sedlak T. Ranolazine for Symptomatic Management of Microvascular Angina. Am J Ther 2020; 27:e151-8. [PMID: 29746286 DOI: 10.1097/MJT.0000000000000779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ranolazine is approved in the United States and Europe for chronic stable angina. Microvascular angina (MVA) is defined as angina with no obstructive coronary artery disease. STUDY QUESTION Our objective was to assess the effectiveness of ranolazine at improving angina scores and quality of life in a Canadian cohort with severe refractory angina due to MVA. STUDY DESIGN We administered questionnaires to 31 patients at baseline and after at least 6 weeks of ranolazine treatment. MEASURES AND OUTCOMES Validated, clinically significant changes for each Seattle Angina Questionnaire domain and the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form were obtained from the literature. Score changes between baseline and postranolazine use were analyzed using sign test. RESULTS Patients were mostly female (27 of 31 patients) with a median age of 57 years. After initiation of ranolazine treatment, patients experienced improvements in Quality of Life Enjoyment and Satisfaction Questionnaire Short Form scores (80.6%; P < 0.01) and in 3 of the 4 domains of the Seattle Angina Questionnaire (physical limitation: 73.3%; P = 0.02; treatment satisfaction: 80.6%; P < 0.01; and disease perception: 77.4%; P < 0.01). Patients were less likely to have interactions with the health care system after ranolazine treatment as compared with before (35.5% vs. 93.5%; P < 0.01). CONCLUSIONS Ranolazine significantly improves symptom control and quality of life in patients with MVA and severe refractory angina and reduces their interaction with the health care system. Given the potentially debilitating effect of chronic angina in MVA, ranolazine may be an effective treatment option.
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Abstract
Heart failure is a complex clinical syndrome and represents the final path of numerous heart diseases. Coronary artery disease is recognized as the primary risk factor for heart failure development, being the main etiological factor in more than 50% of heart failure patients in North America and Europe. Regardless of overt coronary artery disease, myocardial ischemia is a common finding in failing hearts, likely due to structural or functional coronary circulation alterations. Ischemia is a self-propagating process which irreversibly impairs the cardiac function and negatively impacts prognosis. Thus, a better and thorough understanding of myocardial ischemia pathophysiology in heart failure would likely lead to significantly improved outcomes in these patients. This review aims to describe the mechanisms of myocardial ischemia and coronary artery disease in heart failure, focusing on coronary circulation dysfunctions due to increased parietal stress or non-obstructive coronary disease, and discussing the association and management of coronary artery disease in patients with heart failure.
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Affiliation(s)
- Beniamino R Pagliaro
- Cardio Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Francesco Cannata
- Cardio Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Giulio G Stefanini
- Cardio Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy.
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Calcagno S, Infusino F, Salvi N, Taccheri T, Colantonio R, Bruno E, Birtolo LI, Severino P, Lavalle C, Pucci M, Sardella G, Mancone M, Fedele F. The Role of Ranolazine for the Treatment of Residual Angina beyond the Percutaneous Coronary Revascularization. J Clin Med 2020; 9:E2110. [PMID: 32635532 DOI: 10.3390/jcm9072110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Despite a successful percutaneous coronary intervention (PCI), several studies reported that the recurrence of angina after revascularization, even complete, is a particularly frequent occurrence in the first year after PCI. METHODS The aim was to evaluate the efficacy of treatment with ranolazine in addition to conventional anti-ischemic therapy in patients who underwent coronary angiography for persistent/recurrent angina after PCI and residual ischemia only due to small branches not suitable for further revascularization. Forty-nine consecutive patients were included in our registry, adding the ranolazine (375 mg b.i.d) to optimal medical therapy (OMT). The Exercise ECG Test (EET) was performed in all patients before to start the therapy (baseline BL) and at 30 days (T1) after enrollment. RESULTS The average duration of the exercise was increased after the therapy with ranolazine comparing to baseline (RG 9'1'' ± 2' versus BL 8'10'' ± 2', p = 0.01). Seven (14.3%) patients after receiving ranolazine had not crossed the threshold of six minutes (75 watts) compared to 20 (40.8%) of BL (p = 0.0003). Stress angina appeared more frequently at BL than at 30 days (T1 4.1% versus BL 16.3%, p = 0.04) as well as exercise-induced arrhythmias (BL 30.6% versus T1 14.3%, p = 0.05). CONCLUSIONS The addition of ranolazine to standard anti-ischemic therapy showed a significant improvement in EET results after one month of therapy, including reduced exercise angina, increased exercise tolerance, and reduced exercise arrhythmias.
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Pargaonkar VS, Tremmel JA, Schnittger I, Khandelwal A. Effect of ranolazine on symptom and quality of life in patients with angina in the absence of obstructive coronary artery disease: A case control study. Int J Cardiol 2020; 309:8-13. [PMID: 32220488 DOI: 10.1016/j.ijcard.2020.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/02/2020] [Accepted: 02/05/2020] [Indexed: 12/11/2022]
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Turgeon RD, Pearson GJ, Graham MM. Pharmacologic Treatment of Patients With Myocardial Ischemia With No Obstructive Coronary Artery Disease. Am J Cardiol 2018; 121:888-95. [PMID: 29394999 DOI: 10.1016/j.amjcard.2017.12.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/15/2017] [Accepted: 12/27/2017] [Indexed: 12/21/2022]
Abstract
Half of women and 1/3 of men with angina and ischemia on stress testing have ischemia with no obstructive coronary artery disease (INOCA). These patients have quality of life (QoL) impairment comparable with patients with obstructive coronary artery disease. Clinicians generally treat INOCA with traditional antianginal agents despite previous studies demonstrating variable response to these medications. We performed a systematic review to evaluate the efficacy and safety of available pharmacologic therapies for INOCA. We systematically searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and the World Health Organization International Clinical Trials Registry Platform in July 2017 for randomized controlled trials (RCTs) evaluating pharmacologic agents for INOCA. The primary outcome of interest was QoL. Secondary outcomes included subjective and objective efficacy measures and safety outcomes. We included 35 RCTs from 333 identified studies. Interventions that improved QoL with moderate-quality evidence included angiotensin-converting enzyme (ACE) inhibitor (±statin) and ranolazine. Low-to-very-low-quality evidence also suggests that ACE inhibitors, β blockers, calcium-channel blockers, nicorandil, ranolazine, and statins may decrease angina frequency and delay ischemia on stress testing. Other interventions, most notably nitrates, did not significantly improve any outcome. In conclusion, evidence for pharmacologic treatment of INOCA is generally poor, and higher-quality RCTs using a standardized definition of INOCA are needed. Moderate-quality evidence suggests that ACE inhibitors and ranolazine improve QoL. Other interventions had low-quality evidence or no evidence of efficacy.
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Ferrari R, Camici PG, Crea F, Danchin N, Fox K, Maggioni AP, Manolis AJ, Marzilli M, Rosano GMC, Lopez-Sendon JL. A 'diamond' approach to personalized treatment of angina. Nat Rev Cardiol 2017; 15:120-132. [DOI: 10.1038/nrcardio.2017.131] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ahmed B, Mondragon J, Sheldon M, Clegg S. Impact of ranolazine on coronary microvascular dysfunction (MICRO) study. Cardiovasc Revasc Med 2017; 18:431-435. [PMID: 28576663 DOI: 10.1016/j.carrev.2017.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with angina and coronary microvascular dysfunction, without evidence of structural or epicardial coronary disease (Type I CMVD) remain without evidence based treatment options. Previous work has demonstrated that ranolazine can improve angina frequency and stability among patients with Type 1 CMVD; however, the mechanism remains unclear. Therefore, the objective of this pilot project was to assess the impact of ranolazine on Type I CMVD as measured using an invasive tool to measure global resistance (index of microcirculatory resistance (IMR)). METHODS Patients with Type 1 CMVD diagnosed using IMR were enrolled and treated with ranolazine 1000mg BID. Coronary angiography and IMR were performed at baseline and on treatment after four weeks. The primary outcome measure was change in IMR pre- and post-treatment. Secondary outcome measures, improvement in angina and activity level, were assessed using the Seattle Angina Questionnaire (SAQ), Duke Activity Status Index (DASI) and Metabolic equivalent for Task (MET) scores. RESULTS A total of 7 patient were enrolled and completed the study. Mean age was 57.6±7.5, 43% were female and 43% were Hispanic. Mean baseline IMR was 37.25±16.27 which decreased to 19.48±5.69 (p=0.02; (-48% Δ) after treatment with ranolazine. Four of the five SAQ domains improved on treatment with significant improvement in physical limitation (p=0.001), angina frequency (p=0.04), angina stability (p=0.05) and disease perception (p=0.001). Non-significant improvements in activity were also seen in both the DASI and MET scores. CONCLUSION Among patients with Type 1 CMVD, our pilot data suggest favorable changes in IMR, anginal symptoms and activity status with ranolazine treatment. These findings support further evaluation of the effects of ranolazine on microcirculatory function and angina symptoms in a larger cohort of patients with Type 1 CMVD.
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Affiliation(s)
- Bina Ahmed
- Dartmouth Hitchcock Medical Center, Lebanon, NH, United States.
| | - Judith Mondragon
- University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - Mark Sheldon
- University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - Stacey Clegg
- University of New Mexico Health Science Center, Albuquerque, NM, United States
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Abstract
BACKGROUND Stable angina pectoris is a chronic medical condition with significant impact on mortality and quality of life; it can be macrovascular or microvascular in origin. Ranolazine is a second-line anti-anginal drug approved for use in people with stable angina. However, the effects of ranolazine for people with angina are considered to be modest, with uncertain clinical relevance. OBJECTIVES To assess the effects of ranolazine on cardiovascular and non-cardiovascular mortality, all-cause mortality, quality of life, acute myocardial infarction incidence, angina episodes frequency and adverse events incidence in stable angina patients, used either as monotherapy or as add-on therapy, and compared to placebo or any other anti-anginal agent. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and the Conference Proceedings Citation Index - Science in February 2016, as well as regional databases and trials registers. We also screened reference lists. SELECTION CRITERIA Randomised controlled trials (RCTs) which directly compared the effects of ranolazine versus placebo or other anti-anginals in people with stable angina pectoris were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed risk of bias. Estimates of treatment effects were calculated using risk ratios (RR), mean differences (MD) and standardised mean differences (SMD) with 95% confidence intervals (CI) using a fixed-effect model. Where we found statistically significant heterogeneity (Chi² P < 0.10), we used a random-effects model for pooling estimates. Meta-analysis was not performed where we found considerable heterogeneity (I² ≥ 75%). We used GRADE criteria to assess evidence quality and the GRADE profiler (GRADEpro GDT) to import data from Review Manager 5.3 to create 'Summary of findings' tables. MAIN RESULTS We included 17 RCTs (9975 participants, mean age 63.3 years). We found very limited (or no) data to inform most planned comparisons. Summary data were used to inform comparison of ranolazine versus placebo. Overall, risk of bias was assessed as unclear.For add-on ranolazine compared to placebo, no data were available to estimate cardiovascular and non-cardiovascular mortality. We found uncertainty about the effect of ranolazine on: all-cause mortality (1000 mg twice daily, RR 0.83, 95% CI 0.26 to 2.71; 3 studies, 2053 participants; low quality evidence); quality of life (any dose, SMD 0.25, 95% CI -0.01 to 0.52; 4 studies, 1563 participants; I² = 73%; moderate quality evidence); and incidence of non-fatal acute myocardial infarction (AMI) (1000mg twice daily, RR 0.40, 95% CI 0.08 to 2.07; 2 studies, 1509 participants; low quality evidence). Add-on ranolazine 1000 mg twice daily reduced the fervour of angina episodes (MD -0.66, 95% CI -0.97 to -0.35; 3 studies, 2004 participants; I² = 39%; moderate quality evidence) but increased the risk of non-serious adverse events (RR 1.22, 95% CI 1.06 to 1.40; 3 studies, 2053 participants; moderate quality evidence).For ranolazine as monotherapy compared to placebo, we found uncertain effect on cardiovascular mortality (1000 mg twice daily, RR 1.03, 95% CI 0.56 to 1.88; 1 study, 2604 participants; low quality evidence). No data were available to estimate non-cardiovascular mortality. We also found an uncertain effect on all-cause mortality for ranolazine (1000 mg twice daily, RR 1.00, 95% CI 0.81 to 1.25; 3 studies, 6249 participants; low quality evidence), quality of life (1000 mg twice daily, MD 0.28, 95% CI -1.57 to 2.13; 3 studies, 2254 participants; moderate quality evidence), non-fatal AMI incidence (any dose, RR 0.88, 95% CI 0.69 to 1.12; 3 studies, 2983 participants; I² = 50%; low quality evidence), and frequency of angina episodes (any dose, MD 0.08, 95% CI -0.85 to 1.01; 2 studies, 402 participants; low quality evidence). We found an increased risk for non-serious adverse events associated with ranolazine (any dose, RR 1.50, 95% CI 1.12 to 2.00; 3 studies, 947 participants; very low quality evidence). AUTHORS' CONCLUSIONS We found very low quality evidence showing that people with stable angina who received ranolazine as monotherapy had increased risk of presenting non-serious adverse events compared to those given placebo. We found low quality evidence indicating that people with stable angina who received ranolazine showed uncertain effect on the risk of cardiovascular death (for ranolazine given as monotherapy), all-cause death and non-fatal AMI, and the frequency of angina episodes (for ranolazine given as monotherapy) compared to those given placebo. Moderate quality evidence indicated that people with stable angina who received ranolazine showed uncertain effect on quality of life compared with people who received placebo. Moderate quality evidence also indicated that people with stable angina who received ranolazine as add-on therapy had fewer angina episodes but increased risk of presenting non-serious adverse events compared to those given placebo.
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Affiliation(s)
- Carlos A Salazar
- Universidad Peruana Cayetano HerediaDepartment of MedicineAvenida Honorio Delgado 430San Martin de PorresLimaLimaPeru
| | | | | | - Jhon W Mejia Dolores
- Universidad Nacional Mayor de San MarcosFaculty of MedicineAv. Grau 755LimaLimaPeru
| | | | - César Loza Munárriz
- Universidad Peruana Cayetano HerediaDepartment of NephrologyHospital Cayetano HerediaHonorio Delgado 420LimaPeru31
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Affiliation(s)
| | - Tara Sedlak
- University of British Columbia, Vancouver, British Columbia, Canada
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