Exercise Training on Anginal Threshold Does Not Improve Endothelial Function in Refractory Angina Patients.

Refractory angina (RA) is a chronic condition of coronary artery disease (CAD). Endothelial function (EF) measured by flow-mediated dilation (FMD) is an important prognostic marker in CAD. Exercise training is a stimulus that improves EF in CAD. However, exercise training effects on EF in RA are unknown. Therefore, we aimed to verify the effects of exercise training on EF in RA. This was a longitudinal, non-randomized clinical study, involving patients with patients limited by angina, aged 45 to 75 years. Patients were prospectively allocated by convenience to either exercise trained (ET) or control group (C). Laboratory analysis, cardiopulmonary exercise test (CPET), and FMD were implemented at inclusion and after 12 weeks of exercise training or clinical treatment period. Exercise training included 60 minutes per session, 3 times a week, including 40 minutes of aerobic exercise on anginal threshold heart rate obtained on the CPET, 15 minutes of resistance training, and 5 minutes of stretching. A total of 38 patients were included (mean age 60 ± 9 years, 22 men); 21 were allocated to the ET and 17 to the C group. Baseline measures showed no differences between groups. After 12 weeks glycated hemoglobin and systolic blood pressure were lower in ET before than ET after (p = 0.004, and p = 0.05, respectively), and exercise time of the CPET was lower in ET before than ET after (p = 0.002). Exercise training did not change FMD. In conclusion, exercise training performed on anginal threshold increases exercise tolerance but causes no changes in EF in patients with RA.

Cardiopulmonary exercise test in patients with refractory angina: functional and ischemic evaluation.

OBJECTIVES: Refractory angina (RA) is a chronic condition clinically characterized by low effort tolerance; therefore, physical stress testing is not usually requested for these patients. Cardiopulmonary exercise testing (CPET) is considered a gold standard examination for functional capacity evaluation, even in submaximal tests, and it has gained great prominence in detecting ischemia. The authors aimed to determine cardiorespiratory capacity by using the oxygen consumption efficiency slope (OUES) in patients with refractory angina. The authors also studied the O2 pulse response by CPET and the association of ischemic changes with contractile modifications by exercise stress echocardiography (ESE). METHODS: Thirty-one patients of both sexes, aged 45 to 75 years, with symptomatic (Canadian Cardiovascular Society class II to IV) angina who underwent CPET on a treadmill and exercise stress echocardiography on a lower limb cycle ergometer were studied. ClinicalTrials.gov: NCT03218891. RESULTS: The patients had low cardiorespiratory capacity (OUES of 1.74 ± 0.4 L/min; 63.9±14.7% of predicted), and 77% of patients had a flattening or drop in O2 pulse response. There was a direct association between Heart Rate (HR) at the onset of myocardial ischemia detected by ESE and HR at the onset of flattening or drop in oxygen pulse response detected by CPET (R = 0.48; p = 0.019). CONCLUSION: Patients with refractory angina demonstrate low cardiorespiratory capacity. CPET shows good sensitivity for detecting abnormal cardiovascular response in these patients with a significant relationship between flattening O2 pulse response during CEPT and contractile alterations detected by exercise stress echocardiography.

Cardiopulmonary exercise test in patients with refractory angina: functional and ischemic evaluation

Abstract Objectives Refractory angina (RA) is a chronic condition clinically characterized by low effort tolerance; therefore, physical stress testing is not usually requested for these patients. Cardiopulmonary exercise testing (CPET) is considered a gold standard examination for functional capacity evaluation, even in submaximal tests, and it has gained great prominence in detecting ischemia. The authors aimed to determine cardiorespiratory capacity by using the oxygen consumption efficiency slope (OUES) in patients with refractory angina. The authors also studied the O2 pulse response by CPET and the association of ischemic changes with contractile modifications by exercise stress echocardiography (ESE). Methods Thirty-one patients of both sexes, aged 45 to 75 years, with symptomatic (Canadian Cardiovascular Society class II to IV) angina who underwent CPET on a treadmill and exercise stress echocardiography on a lower limb cycle ergometer were studied. ClinicalTrials.gov: NCT03218891. Results The patients had low cardiorespiratory capacity (OUES of 1.74 ± 0.4 L/min; 63.9±14.7% of predicted), and 77% of patients had a flattening or drop in O2 pulse response. There was a direct association between Heart Rate (HR) at the onset of myocardial ischemia detected by ESE and HR at the onset of flattening or drop in oxygen pulse response detected by CPET (R = 0.48; p = 0.019). Conclusion Patients with refractory angina demonstrate low cardiorespiratory capacity. CPET shows good sensitivity for detecting abnormal cardiovascular response in these patients with a significant relationship between flattening O2 pulse response during CEPT and contractile alterations detected by exercise stress echocardiography. Highlights OUES analysis is useful for assessing functional capacity in refractory angina. O2 pulse curve is correlated with contractile alterations in exercise echocardiogram. Cardiopulmonary exercise test is useful toll in patients with refractory angina.

A prospective study of patients with refractory angina: outcomes and the role of high-sensitivity troponin T.

BACKGROUND: The predictors of cardiovascular events in patients with chronic refractory angina are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are biomarkers that may be used to determine the prognosis of patients with stable coronary artery disease. HYPOTHESIS: Hs-cTnT is a predictor of death and nonfatal myocardial infarction (MI) in patients with refractory angina. METHODS: We prospectively enrolled 117 consecutive patients in this study. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms; evidence of myocardial ischemia served as an inclusion criterion. Optimal medical therapy was encouraged via outpatient visits every 6 months; plasma hs-cTnT levels were determined at baseline. The primary endpoint was the composite incidence of death and nonfatal MI. RESULTS: During a median follow-up period of 28.0 months (interquartile range, 18.0-47.5 months), an estimated 28.0-month cumulative event rate of 13.4% was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were hs-cTnT levels and LV dysfunction. Following a multivariate analysis, only hs-cTnT was independently associated with the events in question, either as a continuous variable (hazard ratio per unit increase in the natural logarithm: 2.83, 95% confidence interval: 1.62-4.92, P < 0.001) or as a categorical variable (hazard ratio for concentrations above the 99th percentile: 5.14, 95% confidence interval: 2.05-12.91, P < 0.001). CONCLUSIONS: In patients with chronic refractory angina, plasma concentration of hs-cTnT is the strongest predictor of death and nonfatal MI. Notably, none of the outcomes in question occurred in patients with baseline plasma levels <5.0 ng/L.

OSA and depression are common and independently associated with refractory angina in patients with coronary artery disease.

OBJECTIVE: Refractory angina is a severe form of coronary artery disease (CAD) characterized by persistent angina despite optimal medical therapy. OSA and depression are common in patients with stable CAD and may contribute to a poor prognosis. We hypothesized that OSA and depression are more common and more severe in patients with refractory angina than in patients with stable CAD. METHODS: We used standardized questionnaires and full polysomnography to compare consecutive patients with well-established refractory angina vs consecutive patients with stable CAD evaluated for coronary artery bypass graft surgery. RESULTS: Patients with refractory angina (n = 70) compared with patients with stable CAD (n = 70) were similar in sex distribution (male, 61.5% vs 75.5%; P = .07) and BMI (29.5 ± 4 kg/m2 vs 28.5 ± 4 kg/m2, P = .06), and were older (61 ± 10 y vs 57 ± 7 y, P = .013), respectively. Patients with refractory angina had significantly more symptoms of daytime sleepiness (Epworth Sleepiness Scale score, 12 ± 6 vs 8 ± 5; P < .001), had higher depression symptom scores (Beck Depression Inventory score, 19 ± 8 vs 10 ± 8; P < .001) despite greater use of antidepressants, had a higher apnea-hypopnea index (AHI) (AHI, 37 ± 30 events/h vs 23 ± 20 events/h; P = .001), higher proportion of oxygen saturation < 90% during sleep (8% ± 13 vs 4% ± 9, P = .04), and a higher proportion of severe OSA (AHI ≥ 30 events/h, 48% vs 27%; P = .009) than patients with stable CAD. OSA (P = .017), depression (P < .001), higher Epworth Sleepiness Scale score (P = .007), and lower sleep efficiency (P = .016) were independently associated with refractory angina in multivariate analysis. CONCLUSIONS: OSA and depression are independently associated with refractory angina and may contribute to poor cardiovascular outcome.