Chronic Coronary Syndrome: Medical Therapy or Myocardial Revascularization?

Abstract The best therapeutic strategy for chronic coronary syndrome (CCS) is still controversial. The lack of contemporaneity of medical treatment in many randomized clinical trials prior to the large-scale use of statins, antiplatelet agents, anti-diabetic drugs with cardiovascular protection, and changes in life habits with well-established goals limits the applicability of such studies in current clinical practice. Medical treatment is the only therapeutic option capable of reducing atherosclerotic damage and, therefore, of acting effectively in preventing the progression of this disease. The purpose of this brief review is to critically analyze the main contemporary studies that confront medical treatment with myocardial revascularization in CCS.

Application of shared decision making-based intervention in stable coronary artery disease patients with decisional conflict / 中国实用护理杂志

Object:To explore the effects of shared decision making-based intervention on decisional conflict and health literacy in stable coronary artery disease patients.Methods:A total of 86 stable coronary artery disease patients were divided into experimental group and control group according to the admission order, with 43 cases in each group. The patients in the control group recieved routine nursing, basis on this, the experimental group carried out shared decision making program. Before and after 1 month of intervention, the effects was assessed by Decisional conflict scale (DCS) and Health literacy management scale (HeLMS), respectively.Results:Before intervention, there was no significant difference in DCS and HeLMS scores between two group( P>0.05). After intervention, the information & values, decision uncertainty and total DCS scores were (6.95±2.13) pionts, (3.44±1.18) pionts and (20.95±3.99) pionts, significantly lower than in the control group (8.77±2.33) pionts, (4.95±1.46) pionts, (25.56±4.03) pionts; the information acquisition ability, interaction ability, willingness to improve health, willingness of financial support and total HeLMS scores were (36.77±4.85) pionts, (35.74±4.58) pionts, (15.07±1.55) pionts, (6.53±1.76) pionts, (94.12±6.44) pionts, significantly higher than in the control group [(34.37±5.84) pionts, (33.19±5.90) pionts, (14.23±1.43) pionts, (5.81±1.29) pionts, (87.60±9.18) pionts], the difference was statistically significant ( t values were 2.070-5.321, P<0.05). Conclusion:Shared decision making can effectively alleviate decisional conflict and improve health literacy of patients with stable coronary artery disease.

Correlation between neck circumference and stable coronary artery disease: A cross-sectional study / 西安交通大学学报(医学版)

Objective To investigate the relationship between neck circumference and stable coronary artery disease (SCAD). Methods A total of 1638 patients who had undergone coronary angiography in our hospital from June 2016 to June 2018 were enrolled into this study and analyzed retrospectively. Of them, 756 patients were diagnosed with SCAD and 882 patients were diagnosed with non-CAD. We measured the patients' body fat indexes such as neck circumference and recorded their clinical data and biochemical examination results. The correlation between neck circumference and SCAD in male and female patients was compared by gender. Logistic regression was used to analyze the independent association between the four different neck circumference groups and the occurrence of SCAD. Results Individuals with greater length of neck circumference tended to have a significantly higher prevalence of SCAD in the males (P<0.001), but no significant difference in the female patients. Univariate logistic regression analysis suggested that the risk of SCAD increased gradually with the increase of neck circumference in the males. After adjustment by the factors, multivariate logistic regression analysis indicated that Q2 (OR=1.870, 95% CI: 1.200-2.915, P=0.006), Q3 (OR=1.978, 95% CI: 1.246-3.140, P=0.004) and Q4 (OR=2.299, 95% CI: 1.439-3.674, P<0.001) were associated with the occurrence of SCAD in the males. However, no significant difference was found between the different neck circumference and the occurrence of SCAD in the females. Conclusion The risk of SCAD increased gradually in men with an increased neck circumference. Men with neck circumference above 41.50 cm had the highest prevalence of SCAD. In women, neck circumference was not associated with the prevalence of SCAD.

Relationship between carotid intima-media thickness and aspirin resistance in patients with stable coronary artery disease / 西安交通大学学报(医学版)

Objective: To explore the relationship between carotid intima-media thickness (IMT) and aspirin resistance (AR) in patients with stable coronary artery disease (SCAD). Methods: A total of 316 SCAD patients were enrolled and divided into 3 groups according to IMT measured by carotid artery ultrasound: normal group (n=80), atherosclerosis group (n=102), and plaque group (n=134). Thrombelastogram instrument (TEG) was used to detect platelet aggregation rate (PAG) according to the level of PAG induced by adenosine diphosphate (ADP) to determination AR. The correlation between PAG level (ADP-PAG) and various factors was analyzed, and Logistic regression was used to analyze the risk factors for AR in SCAD patients. Results: The ADP-PAG level was higher in plaque group than in atherosclerosis group and normal group (59.12±11.44 vs. 53.34±10.78 vs. 49.58±11.62, P<0.01); the incidences of AR and aspirin semi-resistance were both higher than those in the other two groups. After adjustment for age and other factors, Logistic regression analysis showed that age (OR=4.08), female (OR=5.06), carotid atherosclerosis (OR=3.57) and carotid plaque (OR=6.35) were independent risk factors for predicting AR in SACD patients (P<0.05). ROC curve analysis revealed that the optimal cutoff of IMT to predict AR in SCAD patients was 1.95 mm, the sensitivity was 86.3%, the specificity was 62.9%, and the area under curve was 0.762 (95% CI: 0.670-0.853, P<0.01). Conclusion: Carotid atherosclerosis is closely related to aspirin resistance in patients with SCAD, and it is an independent risk factor for AR.

A critical analysis of the COMPASS trial with respect to benefit-risk assessment using the numbers needed to treat: Applicability and relevance in Indian patients with stable cardiovascular disease

The recently published Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial evaluated the hypothesis that rivaroxaban alone or in combination with aspirin would be more effective than aspirin alone for secondary prevention. In India, stable cardiovascular disease occurs in a much younger age group relative to the rest of the world. Our critical analysis of COMPASS trial showed that the younger age group appeared to derive greater benefit from the rivaroxaban + aspirin combination (relative to aspirin alone) as seen with number needed to treat metrics as compared to the older age group.

Correlation between circulating uncoupling protein 2 level and severity of coronary artery lesions in patients with stable coronary artery disease / 实用医学杂志

Objective To investigate the correlation between circulating uncoupling protein 2(UCP2) level and severity of coronary artery disease(including Gensini score and criminal vessel counts)in patients with stable coronary artery disease(SCAD),and to analyze the predictive value of circulating UCP2 and urine acid (UA)for SCAD. Methods Three hundred and thirty patients from June 2015 to June 2017 were enrolled. Two hundred and forty patients with SCAD(SCAD group),90 patients without coronary artery disease(control group) were diagnosed. The circulating UCP2 level was detected by enzyme linked immunosorbent assay (ELISA) sandwich method. Results The levels of circulating UCP2 and UA in SCAD group were higher than those in the control group(UCP2[1.60(0.67,4.60)ng/mL]vs.[0.42(0.28,0.59)ng/mL](P<0.01),UA[(365.74 ± 66.06) μmol/L] vs. [(268.11 ± 45.81)μmol/L],P < 0.01). Multivariate logistic regression analysis showed that UCP2 (OR = 1.010 ,95% CI :1.001 ~ 1.020 ,P = 0.025)and UA(OR = 1.039 ,95% CI :1.007 ~ 1.072 ,P < 0.05)were independently associated with SCAD. Correlation analysis showed that the circulating UCP2 level was positively correlated with Gensini score(r=0.780,P<0.01)and criminal vessel counts(r=0.543,P<0.01). The receiver operating characteristic curve(ROC)showed that the optimal cutoff point of the circulating UCP2 level predicting SCAD was 0.64 ng/mL,and the sensitivity was 0.833 and the specificity was 0.944. No significant difference was observed in area under the curve between circulating UCP2 and UA(ΔAUC). Conclusion The high circulating UCP2 level indicates more severe coronary lesions in patients with SCAD. Circulating UCP2 level may be a new indicator of predicting SCAD,equal to the traditional oxidative stress related indicator of serum UA.

Ranolazina como terapia antianginosa adicional en pacientes con enfermedad coronaria estable sintomática / Ranolazine as an additional antianginal therapy in patients with stable symptomatic coronary artery disease

INTRODUCCIÓN: La enfermedad coronaria estable posee varios tratamientos con beneficio probado tanto en mortalidad como en incidencia de eventos agudos. Sin embargo, el control de los síntomas, especialmente en aquellos que no responden a terapia de primera línea, sigue siendo controvertido. Este resumen pretende evaluar el papel de la ranolazina como terapia adicional al tratamiento antianginoso estándar en pacientes que persisten sintomáticos a pesar de éste. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cuatro revisiones sistemáticas que en conjunto incluyeron 16 estudios primarios, todos correspondientes a ensayos aleatorizados, de los cuales cuatro son atingentes para la pregunta específica. Concluimos que en pacientes con enfermedad coronaria estable que persisten sintomáticos a pesar de terapia antianginosa estándar, el tratamiento adicional con ranolazina podría disminuir los episodios de angina semanales pero aumentando la incidencia de efectos adversos, y resulta en poca o nula diferencia en el riesgo de muerte o infarto agudo al miocardio.

INTRODUCTION: There are several effective therapeutic alternatives for stable coronary artery, in terms of prevention of cardiovascular morbidity and mortality. However, the best way to achieve symptomatic control is a matter of debate, particularly in those who do not respond to first-line therapy. This summary aims to evaluate the role of ranolazine as an additional therapy to standard antianginal treatment in patients with persistent symptoms. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified four systematic reviews including 16 studies overall, all of which were randomized trials. We concluded additional treatment with ranolazine might decrease the frequency of anginal episodes but increase adverse effects. It probably has no effect on the risk of death or acute myocardial infarction.

Impact of ticagrelor adherence on cardiovascular outcomes in pateints with stable coronary artery diseases / 中国介入心脏病学杂志

Objective Ticagrelor-related dyspnea may affect the medication adherence of patients with coronary artery disease.This study aims to assess the impact of ticagrelor adherence on 1-year cardiovascular outcomes in pateints with stable coronary artery diseases (SCAD).Methods This study includes the patients with SCAD from Fuwai hospital who discharged with ticagrelor between Jan.2015 to Jun.2015.We collected data of clinical characteristics and ticagrelor adherence from these patients by reviewing the electronic medical records and personnel interview.Follow-up was performed at 6 and 12 months by telephone interview or office visits.Results A total of 155 patients with SCAD were enrolled,of whom 122 (78.7％) were males with a mean age (57.0 ± 10.0) years.Among them,50 (32.3％) patients have a history of myocardial infraction and 106 (68.4％) patients had angiographic confirmed left main and/or multivessel disease.Forty-six patients (29.7％) with SCAD prematurely stopped ticagrelor within 12 months,while 25 (16.1％) patients switched from ticagrelor to clopidogrel.Hemorrhagic events and locally unavailable ticagrelor were the major reasons causes of the premature discontinuation of ticagrelor.Univariate analysis showed age,body mass index (BMI),hypertention and locally unavailable ticagrelor as relative factors for early ticagrelor discontinuation after discharge.Multivariate analysis revealed unavailable drug locally (OR 0.25,95％ CI 0.09-0.69) and elderly patients (OR 4.13,95％ CI 1.40-12.19) were risk factors for low persientence or premature ticagrelor discontinuation.Conclusion This study showed poor ticagrelor adherence in patients with SCAD after discharge.Locally unavailable ticagrelor and elderly patients were strong predictors of poor ticagrelor adherence.Discontinuation to ticagrelor prematurely may not have impact on adverse cardiovascular outcomes.

Effect of CYP2C19 polymorphism on platelet P2Y12 receptor signaling pathway in Chinese patients with stable coronary artery disease after the treatment of clopidogrel / 复旦学报（医学版）

Objective To investigate the molecular mechanism of the effect of CYP2C19 polymorphism on the efficacy of clopidogrel in patients with stable coronary artery disease (SCAD).Methods A total of 208 patients with coronary artery disease undergoing percutaneous coronary intervention (PCI) were included.The CYP2C19 variant alleles were detected by gene sequencing.Platelet reactivity was assessed by thrombelastograph at 24 h after 300 mg clopidogrel loading.P2Y12-Gi signaling was measured by flow cytometric analysis of vasodilator-stimulated phosphorylation-platelet reactivity index (VASP-PRI) and Akt phosphorylation (P-Akt) index.Results Among 208 patients,40.9％ were classified as CYP2C19 * 1/* 1 (non-carriers) with no loss-of-function (LOF),44.7％ as CYP2C19 * 1/* 2 or CYP2C19 * 1/* 3 (one LOF carriers) and 14.4％ as CYP2C19 * 2/*2 or CYP2C19 * 2/* 3 (two LOF carriers).Both postclopidogrel platelet aggregation and VASP-PRI increased by the presence of one LOF allele,and were even more pronounced with the presence of two LOF alleles.In contrast,P-Akt index only increased in two LOF carriers.VASP-PRI was positively associated with postclopidogrel platelet aggregation (r =0.661,P＜0.001),but not with P-Akt index.Conclusions The two CYP2C19 LOF carriage was associated with more active state of P2Y12-Gi signaling in postclopidogrel platelet in Chinese patients with SCAD.

Predictores de arterias coronarias angiográficamente normales en pacientes estables con sospecha de enfermedad coronaria / Predictors of Angiographically Normal Coronary Arteries in Stable Patients with Suspected Coronary Disease

Introducción: La cinecoronariografía (CCG) es la prueba que se constituye en el estándar de oro para identificar a pacientes con coronariopatía. Pese a que se prevé una proporción de CCG normales, este estudio debe minimizarse, dados su carácter invasivo, el riesgo asociado y el aumento del costo en salud. Objetivos: Determinar las características, los patrones epidemiológicos y las variables relacionadas con el hallazgo de arterias coronarias angiográficamente "normales" en pacientes estables derivados para la realización de una CCG. Material y métodos: Se analizaron las CCG de 12.686 pacientes de cinco centros de Buenos Aires. Todos los datos se obtuvieron en forma retrospectiva entre 2008 y 2013. Se definió "normal" a una CCG con lesiones < 50%. Se compararon las características demográficas, los factores de riesgo habituales, la presencia de insuficiencia renal crónica, de hipotiroidismo y de enfermedad vascular periférica, los síntomas, los estudios evocadores de isquemia y la cobertura social entre el grupo con CCG "normal" y los pacientes con coronariopatía obstructiva = 50%. Resultados: De los 3.990 pacientes incluidos (31,5%), el 38,6% presentaba una CCG normal. El sexo femenino fue el mayor predictor independiente para este hallazgo. Además, la menor edad y la ausencia de síntomas compatibles con isquemia se asociaron con una probabilidad mayor de una CCG "normal". Conclusiones: En una población derivada para CCG con diagnóstico de enfermedad arterial coronaria estable, el género femenino, la menor edad y la ausencia de síntomas se relacionaron con el hallazgo de arterias coronarias angiográficamente "normales". Un mejor uso de los modelos de estratificación clínica podría optimizar el rendimiento de la CCG para detectar pacientes con enfermedad arterial coronaria significativa, limitando así los estudios innecesarios.

Introduction: Coronary angiography (CA) is the gold standard test to identify patients with coronary artery disease. Despite a proportion of normal CAs is expected, this study should be minimized, given its invasive nature, the associated risk and increased health costs. Objectives: The aim of this study was to establish the characteristics, epidemiological patterns and variables associated to angiographically "normal" coronary arteries in stable patients referred for CA. Methods: Coronary angiographies were analyzed in 12,686 patients from five centers in Buenos Aires. All data were retrospectively obtained from 2008 to 2013. Coronary angiographies with < 50% lesions were defined as "normal". Demographic characteristics, usual risk factors, chronic renal failure, hypothyroidism, peripheral vascular disease, symptoms, ischemia-inducing tests and social coverage were compared between the group with "normal" CA and patients with = 50% obstructive coronary disease. Results: Among the 3,990 patients included in the study (31.5%), 38.6% had a normal CA, and female gender was the most important independent predictor for this finding. In addition, younger age and absence of ischemic symptoms were associated with greater probability of "normal" CA. Conclusions: In a population referred for CA diagnosed with stable coronary artery disease, female gender, younger age and absence of symptoms were associated with angiographically "normal" coronary arteries. Better use of clinical stratification models could optimize CA performance to detect patients with significant coronary artery disease, limiting unnecessary studies.