Treatment of Angina: Where Are We?

Abstract

Ischaemic heart disease is a major cause of death and disability worldwide, while angina represents its most common symptom. It is estimated that approximately 9 million patients in the USA suffer from angina and its treatment is challenging, thus the strategy to improve the management of chronic stable angina is a priority. Angina might be the result of different pathologies, ranging from the “classical” obstruction of a large coronary artery to alteration of the microcirculation or coronary artery spasm. Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revascularization. In the current guidelines, drugs are classified as being first-choice (beta-blockers, calcium channel blockers, and short-acting nitrates) or second-choice (ivabradine, nicorandil, ranolazine, trimetazidine) treatment, with the recommendation to reserve second-line modifications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. However, such a categorical approach is currently questioned. In addition, current guidelines provide few suggestions to guide the choice of drugs more suitable according to the underlying pathology or the patient comorbidities. Several other questions have recently emerged, such as: is there evidence-based data between first- and second-line treatments in terms of prognosis or symptom relief? Actually, it seems that newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than what is available for the first-choice drugs. It follows that actual guidelines are based more on tradition than on evidence and there is a need for new algorithms that are more individualized to patients, their comorbidities, and pathophysiological mechanism of chronic stable angina.

<p>Targeting Cardiac Metabolic Pathways: A Role in Ischemic Management</p>

“…Although recent advances with these approaches have been made, there are still patients ineligible or refractory to this conventional treatment. 7 Metabolic modulation is among the promising strategies in the treatment of IHD, because alterations in energy metabolism are known to be involved in the progression of the disease. Insufficient energy supply to the heart impairs energy sources of the heart and contributes to the progression of the disease.…”

“…23 Inhibition of MCD or increased cardiac malonyl CoA levels decreases cardiac FA-oxidation rates and further improves cardiac efficiency. 7 …”

Sublingual spray: a new technology oriented formulation with multiple benefits

“…Following sublingual administration, nitrates appear in plasma and persisted for 24h (Richman et al, 1965;Tarkin and Kaski, 2016). Sublingual Verapamil (a calcium channel antagonist prescribed for the management of angina, hypertension and certain supraventricular arrhythmias) was found to be effective in controlling the ventricular rate following sublingual administration (John et al, 1992;Balla et al, 2018). Absorption of a drug through the oral mucosa depends on the lipid solubility, permeability, pH and the molecular weight of the drug.…”

Indicators of Inflammation in the Pathogenesis of Unstable Angina

“…Cardiovascular disease is a leading cause of population disability and mortality worldwide, and angina is the most common symptom of cardiovascular disease [1,2,3,4,5]. At last count, approximately 9 million people in the United States have coronary heart disease [4]. For the last two decades, ischemic heart disease mortality in Poland increased in people under 65 [3].…”