Emerging drugs for the treatment of angina pectoris

Abstract

Angina pectoris, or symptomatic myocardial ischaemia, reflects an impairment of coronary blood flow, and usually a deficiency of available myocardial energetics. Treatment options vary with the precise cause, which may vary with regards to the roles of increased myocardial oxygen demand versus reduced supply. Traditionally, organic nitrates, β-adrenoceptor antagonists, and non-dihydropyridine calcium antagonists were the only commonly used prophylactic anti-anginal agents. However, many patients failed to respond adequately to such therapy, and/or were unsuitable for their use. Areas covered: A number of 'new' agents have been shown to represent ancillary forms of prophylactic anti-anginal therapy and are particularly useful in patients who are relatively unsuitable for either percutaneous or surgical revascularisation. These include modulators of myocardial metabolic efficiency, such as perhexiline, trimetazidine and ranolazine, as well as high dose allopurinol, nicorandil and ivabradine. The advantages and disadvantages of these various agents are summarized. Expert opinion: 'Optimal' medical treatment of angina pectoris now includes use of agents primarily intended to reduce risk of infarction (e.g. statins, aspirin, ACE inhibitors). In patients whose angina persists despite the use of 'standard' anti-anginal therapy, and who are not ideal for invasive revascularization options, a number of emerging drugs offer prospects of symptomatic relief.

Late coronary ischemıc syndromes assocıated wıth transcatheter aortıc valve ımplantatıon: A revıew of mechanıstıc and clınıcal aspects

“…As described previously, substantial reduction in coronary perfusion without coronary embolism or thrombus may be the predominant mechanism in a portion of patients with TAVI even in the absence of pre-existing coronary macro or microvascular disease. Therefore, therapies targeting enhancement of myocardial blood flow including newer generation calcium channel blockers 32 etc.and other antiischemics (beta blockers, ranolazine, trimethazidine) 33 , 34 may be initiated soon after TAVI. It seems reasonable to initiate more intensive regimens much earlier in the setting of a pre-existing microvascular disease or a critical coronary stenosis that is not amenable to PCI in the pre-TAVI setting.Hypercoagulable states including smoking, 35 etc.…”

“…Other highly thrombogenic procedures including elective coronary stent implantation, 37 where necessary, should be performed in the pre-TAVI setting, and importantly; if possible, deferring TAVI until the implanted coronary stent is considered to be fully endothelialized, may be a safer strategy. Therefore, bare metal stents may be preferred over drug-eluting ones due to their higher rates of endothelialization.Since TAVI may have the potential to reduce coronary shear stress potentially associated with de-novo or accelerated atherogenesis, a variety of antiatherosclerotic drugs including statins, ACE inhibitors 33 should also be initiated on a routine basis. Fortunately, majority of these patients already receive statin therapy prior to TAVI as part of a primary or secondary preventive strategy against stable CAD and ACS.…”

“…Since TAVI may have the potential to reduce coronary shear stress potentially associated with de-novo or accelerated atherogenesis, a variety of antiatherosclerotic drugs including statins, ACE inhibitors 33 should also be initiated on a routine basis. Fortunately, majority of these patients already receive statin therapy prior to TAVI as part of a primary or secondary preventive strategy against stable CAD and ACS.…”

Therapy of Stable Angina of Effort by Triple Combinations of Antianginal Drugs in Geriatric Practice

“…Между тем увеличение их дозы сопрово-ждается ухудшением переносимости, что особенно часто наблюдается в гериатрической практике. В подобных случаях, при невозможности проведения чрескожной или хирургической реваскуляризации миокарда, могут ока-заться полезными антиангинальные препараты второй линии [5].У больных ИБС пожилого и старческого возраста при-менение бета-адреноблокаторов в дозах, которые обе-спечивают достижение целевой частоты сердечных сокращений, нередко приводит к появлению атриовен-трикулярной блокады и других побочных эффектов. Добавление ивабрадина к сниженной дозе бета-адрено-блокатора оказывается более безопасным и достаточно эффективным, но не устраняет стенокардию полностью [6].…”

“…Между тем увеличение их дозы сопрово-ждается ухудшением переносимости, что особенно часто наблюдается в гериатрической практике. В подобных случаях, при невозможности проведения чрескожной или хирургической реваскуляризации миокарда, могут ока-заться полезными антиангинальные препараты второй линии [5].…”