Non-PCI/CABG therapies for refractory angina.

Angina persists for many patients despite modern medical therapy and/or revascularization, and this is referred to as refractory angina. All patients with refractory angina must be treated with aggressive risk factor modification plus optimized medical management. ß-Blockers and nitrates are usually first-line agents; however most patients require multiple medications for refractory symptom control. Novel agents, such as ranolazine and ivabradine, as well as non-pharmacologic therapies, such as enhanced external counterpulsation and cardiac rehabilitation, may provide relief or reduction of angina. Other standard treatments such as antiplatelet therapy, lipid reduction therapy, blood pressure control, diabetes control, smoking cessation, and wei1ght control should be part of the management of refractory angina as well.

Obesity and Weight Loss.

The entire world is becoming overweight. Most people are motivated to try to lose weight for cosmetic reasons. Weight loss can decrease health risk factors and possibly improve prognosis. Weight loss can be difficult in people who are trying to stop smoking, as they tend to gain weight. Many weight loss systems are available and are not inexpensive. Athletes who are obese and fit must lose weight after retirement or suffer the consequences related to risk factors. Bariatric surgery seems to be the best way for morbidly obese patients to lose weight, assuming that they adhere to principles of risk factor modulation. Weight-loss medications work in most patients who also comply with lifestyle changes, but these drugs have a number of side-effects.

Historical perspective and contemporary management of acute coronary syndromes: from MONA to THROMBINS2.

Acute coronary syndrome (ACS) remains a major burden on morbidity and mortality in the United States. Medical professionals and students often use the mnemonic 'MONA' (morphine, oxygen, nitroglycerin and aspirin) to recall treatments for ACS; however, this list of therapies is outdated. We provide a historical perspective on 'MONA,' attempt to uncover its origin in the medical literature, and demonstrate the myriad changes that have occurred over the last 50 years of ACS management. We have developed a novel mnemonic, 'THROMBINS2' (thienopyridines, heparin/enoxaparin, renin-angiotensin system blockers, oxygen, morphine, beta blocker, intervention, nitroglycerin, statin/salicylate) to help bedside clinicians recall all the elements of contemporary ACS management. We demonstrate the mortality benefit for each component of contemporary ACS management, correlating the continued improvement with historical data on mortality after myocardial infarction. We encourage providers to utilize this mnemonic to explore options and guide treatments in ACS patients.

Fractional flow reserve: an updated review.

Revascularization of ischemia-producing coronary lesions is widely used in the management of coronary artery disease. However, some coronary lesions appear significant on the conventional angiogram when they are truly non-flow limiting. For this reason, it is becoming increasingly important to determine the coronary physiology. Fractional flow reserve (FFR) has emerged as a useful tool to determine the lesions that require revascularization. Measurement of FFR during invasive coronary angiography now has a class IA indication from the European Society of Cardiology for identifying hemodynamically significant coronary lesions when noninvasive evidence of myocardial ischemia is unavailable. Current data on FFR can be broadly classified into studies that compare the diagnostic accuracy of FFR measurement compared with other noninvasive modalities and studies that test treatment strategies of patients with intermediate coronary stenoses using a threshold value for FFR and that have clinical outcomes as endpoints. In this review, we will discuss the concept of FFR, current evidence supporting its usage, and future perspectives.

Caseous calcification of the mitral annulus: a review.

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification (MAC). Since most cardiologists are unfamiliar with CCMA, it is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. In most cases, conservative management for this lesion is sufficient. In this review, we will discuss the various aspects of this condition and illustrate the gross and histologic pathology as well as various imaging modalities (Ultrasound, Computed tomography, Cardiac Magnetic resonance) to assess this unusual cardiac mass.

[Ion channel therapy of ischemic heart disease].

Basic studies have shown a variety of ion channels are involved in the pathogenesis of ischemic heart disease, including L type Ca(2+) channel, T type Ca(2+) channel, ATP-sensitive potassium channel, If (funny) channel and late Na(+) channel. Clinical studies showed that the regulation of these channels function can improve myocardial blood supply and metabolism of myocardium. What is summarized below relates to the clinical usefulness of various ion channel antagonists reviewed by a clinical cardiologist, not a basic scientist working on ion channel biology.

[Automated external defibrillators, life vest defibrillator, or both?].

As most understand, survival of cardiac arrest victims falls significantly if cardioversion is not performed promptly. The standard of practice for out-of-hospital defibrillation is the implantable cardiac defibrillator; however, much has been written and discussed about the use of automated external defibrillators. Not as much has been written about life vest wearable defibrillators. How to use these devices will be reviewed in this article.

Silent ischemia: clinical relevance.

Myocardial ischemia can occur without overt symptoms. In fact, asymptomatic (or silent) ST-segment depression during ambulatory electrocardiogram monitoring occurs more often than symptomatic ST-segment depression in patients with coronary artery disease. Initial studies documented that silent ischemia provided independent prediction of adverse outcomes in patients with known and unknown coronary artery disease. The ACIP (Asymptomatic Cardiac Ischemia Pilot Study) enrolled patients in the 1990s and found that revascularization was better than medical therapy in reducing silent ischemic episodes and possibly cardiovascular (CV) events. However, the more recent COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial found similar CV event rates between patients treated with optimal medical therapy alone and those treated with optimal medical therapy plus percutaneous revascularization. Therefore, in the current era, medical therapy appears to be as effective as revascularization in suppressing symptomatic ischemia and preventing CV events. COURAGE was not designed to evaluate changes in the frequency of silent ischemia. Therefore, silent ischemia may persist despite current-era treatment and might still identify patients with increased risk of CV events. Also, silent ischemia is likely to occur frequently in heart transplant patients with denervated hearts and coronary allograft vasculopathy, and future study aimed at improving the management of silent ischemia in this population is warranted. Additionally, future research is warranted to study the effect of newer medical therapies such as ranolazine or selected use of revascularization (for example, guided by fractional flow reserve) in those patients with persistent silent ischemia despite optimal current-era medical therapy.