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Enhanced external counterpulsation: A unique treatment for the "No-Option" refractory angina patient.
Caceres, J, Atal, P, Arora, R, Yee, D
Journal of clinical pharmacy and therapeutics. 2021;(2):295-303
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Abstract
WHAT IS KNOWN AND OBJECTIVES Coronary artery disease (CAD) is the leading cause of death in the United States. For patients on whom guideline-driven measures have been tried, enhanced external counterpulsation (EECP) is the only truly noninvasive and safe intervention for which a reduction of angina symptoms and nitrate use, increased exercise tolerance, and improvement in myocardial ischaemia have been shown. The objective of this study was to demonstrate, by way of literature review, the efficacy of EECP as a treatment modality for the relief of refractory angina and improvement in quality of life in CAD patients. METHODS This article reviewed the safety and efficacy of EECP in patients with refractory angina, by conducting a sweeping search and analysis of existing published literature. RESULTS AND DISCUSSION Critical review of a multitude of studies revealed that EECP consistently reduces angina pectoris, extends time to exercise-induced ischaemia, decreases dependency on nitroglycerine for frequent chest pain, increases maximum workload, and improves the quality of life in patients with symptomatic stable angina. The literature reviewed also indicated that EECP is well-tolerated by the vast majority of patients, with relatively few adverse events reported. CONCLUSION The present study suggests that EECP is a safe and likely best available method of treatment for patients presenting with symptomatic CAD not amenable to further revascularization.
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Comparative efficacy of Chinese herbal injections for angina pectoris: A Bayesian network meta-analysis of randomized controlled trials.
Wang, K, Wu, J, Duan, X, Zhang, D, Lin, X, Zhang, S, Ni, M, Liu, S, Meng, Z, Gao, X, et al
Complementary therapies in medicine. 2019;:208-217
Abstract
OBJECTIVE The severity of angina pectoris has been recognized. It is believed that Chinese herbal injections have an outstanding clinical effect on this condition. This network meta-analysis was devised to investigate the comparative efficacy of eight Chinese herbal injections (Ciwujia injection, Dazhuhongjingtan injection, Huangqi injection, Shenfu injection, Shengmai injection, Shenmai injection, Shenqi Fuzheng injection, Yiqifumai injection) in the treatment of angina pectoris. METHODS A literature search was performed in PubMed, Embase, and the Cochrane Library, Chinese Biological Medicine Database, China National Knowledge Infrastructure, Wanfang Database, and Chinese Scientific Journal Database from their inception to June 25, 2018. A pre-designed eligibility criterion was utilized in this network meta-analysis, and a methodological quality analysis was conducted. Data analysis was performed by WinGUGS 1.4.3, Stata 13.0 and TSA software, and the odds ratio or mean difference with the 95% credible interval was reported for symptomatic improvement, electrocardiography improvement, fibrinogen, triglyceride and cholesterol. The ranking probability of interventions in various outcomes was also utilized. RESULTS A total of 73 randomized controlled trials with 6639 patients were identified. Integrating network meta-analysis results, Shenqi Fuzheng injection plus western medicine therapy and Shenmai injection plus western medicine therapy were shown to be more efficacious than other therapies. In addition, Huangqi injection plus western medicine therapy and Shenmai injection plus western medicine therapy performed well in improving the haemorheology index and serum lipid parameters. CONCLUSIONS Eligible Chinese herbal injections plus western medicine therapy might have a better impact on angina pectoris patients than western medicine therapy alone. While this study had limitations, the findings should be interpreted with caution. In addition, more high-quality randomized controlled trials with a large sample must be conducted to support this study.
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Efficacy and safety of oral Panax notoginseng saponins for unstable angina patients: A meta-analysis and systematic review.
Duan, L, Xiong, X, Hu, J, Liu, Y, Wang, J
Phytomedicine : international journal of phytotherapy and phytopharmacology. 2018;:23-33
Abstract
BACKGROUND Panax notoginseng saponins (PNS) is one of the most important active ingredients in Panax notoginseng, which plays an important role against cardiovascular diseases in Traditional Chinese Medicine (TCM). METHODS This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We searched the following databases from their inception to February 2017: CENTRAL, MEDLINE, EMBASE Database, WHO ICTRP, CNKI, WANFANG, VIP and SinoMed. All the randomized controlled trials (RCTs) based on PNS in patients with unstable angina (UA) which meet the standard were included. RESULT Seventeen studies were included in this systemic review. The included studies indicated that PNS has promising therapeutic effects on reduction of the primary end point [RR 0.05 (95% CI -0.07, -0.02); P < 0.001], electrocardiography (ECG) [RR 0.32 (95% CI 0.23, 0.46); P < 0.001], the frequency and duration of angina attacks [MD -1.88 (95% CI -2.03, -1.72); P < 0.001], and dosage of nitroglycerin [MD -1.13 (95% CI -1.70, -0.56); P < 0.001] of UA patients. Adverse events were described 9 included RCTs. CONCLUSION Oral PNS could reduce the end point, and improve the ECG, the frequency and duration of angina pectoris, dosage of nitroglycerin and lipids in UA patients. And the results indicated oral PNS is safe up to now. However, we need more multi-centre, large-sample, high-quality RCTs to provide high-quality evidence.
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A Chinese patent medicine Salvia miltiorrhiza depside salts for infusion combined with conventional treatment for patients with angina pectoris: A systematic review and meta-analysis of randomized controlled trials.
Zhang, Y, Xie, Y, Liao, X, Jia, Q, Chai, Y
Phytomedicine : international journal of phytotherapy and phytopharmacology. 2017;:100-117
Abstract
BACKGROUND Currently, many trials have been conducted to investigate the beneficial and harmful effects of Salvia miltiorrhiza depside salts for infusion for treating patients with angina pectoris. It is important to systematically and criticallyevaluate the existing literature into providing a pooled effect to examine outcomes of angina pectoris with Salvia miltiorrhiza depside salts for infusion. PURPOSE A systematic review and meta-analysis were performed to determine the clinical curative effect and safety of Salvia miltiorrhiza depside salts for infusion for angina pectoris and provide clear evidence to inform clinical practice. METHOD The Cochrane Library, MEDLINE, EMBASE, and other four electronic Chinese databases were searched to identify relevant randomized controlled trials. Methodological quality and reporting quality of eligible studies was evaluated by using the Cochrane risk-of-bias tool and CONSORT for traditional Chinese medicine respectively. Meta-analysis was performed by RevMan 5.3 software. RESULT Fifty-six randomized controlled trials involving 5503 patients were included. Most of the trials were classified as having an unclear risk of bias because of poor reported methodology. The main outcomes are improvements in angina symptoms, ECG improvement and reduction of nitroglycerin use. CHD mortality or rate of CHD events was not reported in any trial. Meta-analysis showed that Salvia miltiorrhiza depside salts for infusion combined with conventional treatment was better than conventional treatment alone in improving angina symptoms (RR= 1.28, 95% CI 1.24 to 1.31, p < 0.00001), the frequency of angina attack (time/week)(WMD=-1.47, 95% CI -2.16 to -0.78), reducing clinical symptom scores (WMD=-0.55, 95% CI -0.57 to -0.53, p < 0.000011), increasing physical limitation scores (WMD= 7.68, 95% CI 1.48 to 13.88, p = 0.02), improving ECG (RR= 1.32,95% CI 1.27 to 1.38, p < 0.00001) and reducing dosage of nitroglycerin (RR= 1.50, 95% CI: 1.26 to 1.77, p < 0.00001). In addition, Egger's regression tests was found there was publication bias (Kendall' tau= 0.36, p < 0.01). CONCLUSION The current systematic review indicates relevant evidence for Salvia miltiorrhiza depside salts for infusion combined with conventional treatments treating patient with angina pectoris. However, the results should be interpreted with caution due to the low methodological quality, the risk of publication bias, lack of important clinically relevant outcomes and inadequate reporting on adverse events of the included trials. International methodological and reporting standards could help researchers conduct well designed trials and generate better evidence for Salvia miltiorrhiza depside salts for infusion.
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WITHDRAWN: Trimetazidine for stable angina.
Ciapponi, A, Pizarro, R, Harrison, J
The Cochrane database of systematic reviews. 2017;(3):CD003614
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Abstract
BACKGROUND Patients with stable angina not controlled by monotherapy with nitrates, beta blockers, or calcium channel blockers are often treated with combinations of these drugs. There may be adverse effects from, or contraindications to, the use of combinations. In low risk groups, medical treatment appears to be as good an option as percutaneous transluminal coronary angioplasty in terms of averting myocardial infarction, death, or subsequent revascularization. Revascularization procedures are too costly or inaccessible for many patients in developing countries therefore effective and safe medical treatment is needed. Trimetazidine is a less well known anti-anginal drug that controls myocardial ischaemia through intracellular metabolic changes. Trimetazidine has been reported, in some studies, to be better tolerated than combined anti-anginal therapy; however it is not considered in published guidelines. OBJECTIVES To determine the efficacy and tolerability of trimetazidine in patients with stable angina. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS and SCISEARCH, without language restriction, from inception to October 2003. Experts in the field were contacted to locate unpublished studies. SELECTION CRITERIA Randomised studies comparing trimetazidine with placebo, or other anti-angina drug in adults with stable angina. DATA COLLECTION AND ANALYSIS Two reviewers independently applied the inclusion criteria, assessed trial quality and extracted data. MAIN RESULTS Twenty-three studies (1378 patients) met the inclusion criteria. There was a paucity of information about mortality, cardiovascular events and quality of life. Trimetazidine, compared with placebo, reduced the number of weekly angina attacks ( mean difference -1.44, 95% CI -2.10 to -0.79; P < 0.0001), reduced weekly nitroglycerin tablet consumption (95% CI -1.47 to -2.20, -0.73; P < 0.0001) and improved exercise time to 1 mm segment depression (P = 0.0002). Four small trials (263 patients) compared trimetazidine against other anti-anginal agents. One favoured trimetazidine over nitrates. Three tended to favour alternative regimens but with confidence intervals consistent with both major increases and decreases in frequency of angina episodes. In this subgroup, adverse events were considered in 5 trials (448 patients) and totals of 2 versus 12 drop outs due to adverse events were observed in the trimetazidine and alternative regimens respectively, but this was mostly driven by a single trial. AUTHORS' CONCLUSIONS Trimetazidine is effective in the treatment of stable angina compared with placebo, alone or combined with conventional anti-anginal agents. Trimetazidine may result in fewer dropouts due to adverse events. Large, long term trials comparing trimetazidine with other anti-anginal drugs assessing clinically relevant important outcomes are required to establish its role in clinical management.
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Traditional and Alternative Therapies for Refractory Angina.
Kocyigit, D, Gurses, KM, Yalcin, MU, Tokgozoglu, L
Current pharmaceutical design. 2017;(7):1098-1111
Abstract
Refractory angina (RFA) is an unfavourable condition that is characterized with persistent angina due to reversible myocardial ischemia in patients with coronary artery disease that remains uncontrollable despite an optimal combination of pharmacological agents and revascularization. Despite significant advances in revascularization techniques and agents used in pharmacological therapy, there is still a significant population suffering from RFA and the global prevalence is even increasing. Anti- anginal treatment and secondary risk-factor modification are the traditional approaches for this group of patients. Furthermore, now there is still a large number of alternative treatment options. In order to review traditional and alternative treatment strategies in patients with RFA, we searched Pubmed for articles in English using the search terms "pharmacological therapy, refractory angina", "alternative therapy, refractory angina" between inception to June 2016. We also went through separately for each alternative treatment modality on Pubmed. To identify further articles, we handsearched related citations in review articles and commentaries. We also included data from the European Society of Cardiology (2013), and the Canadian Society of Cardiology/ Canadian Pain Society (2012) guidelines. Data show that besides traditional pharmacological agents, such as nitrates, beta- blockers or calcium channel blockers, novel antiischemic drugs and if symptoms persist, several non- invasive and/ or invasive alternative strategies may be considered. Impact of some pharmacological agents, such as rho- kinase inhibitors, and novel alternative treatment modalities, such as coronary sinus reducers, stem cell therapy, gene and protein therapy, on outcomes are still under investigation.
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Pharmacological and emerging therapies in the treatment of chronic angina.
Husted, SE, Ohman, EM
Lancet (London, England). 2015;(9994):691-701
Abstract
Chronic angina is a common manifestation of ischaemic heart disease. Medical treatments are the mainstay approach to reduce the occurrence of angina and improve patients' quality of life. This Series paper focuses on commonly used standard treatments (eg, nitrates, β blockers, and calcium-channel blockers), emerging anti-angina treatments (which are not available in all parts of the world), and experimental treatments. Although many emerging treatments are available, evidence is scarce about their ability to reduce angina and ischaemia.
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More answers to the still unresolved question of nitrate tolerance.
Münzel, T, Daiber, A, Gori, T
European heart journal. 2013;(34):2666-73
Abstract
Organic nitrates are traditionally felt to be a safe adjuvant in the chronic therapy of patients with coronary artery disease. Despite their long use, progress in the understanding of the pharmacology and mechanism of action of these drugs has been achieved only in the last two decades, with the identification of the role of oxidative stress in the pathophysiology of nitrate tolerance, with, the discovery of the ancillary effects of nitrates, and with the demonstration that nitrate therapy has important chronic side effects that might modify patients' prognosis. These advances are however mostly confined to the molecular level or to studies in healthy volunteers, and the true impact of organic nitrates on clinical outcome remains unknown. Complicating this issue, evidence supports the existence of important differences among the different drugs belonging to the group, and there are reasons to believe that the nitrates should not be treated as a homogeneous class. As well, the understanding of the effects of alternative nitric oxide (NO) donors is currently being developed, and future studies will need to test whether the properties of these new medications may compensate and prevent the abnormalities imposed by chronic nitrate therapy. Intermittent therapy with nitroglycerin and isosorbide mononitrate is now established in clinical practice, but they should neither be considered a definitive solution to the problem of nitrate tolerance. Both these strategies are not deprived of complications, and should currently be seen as a compromise rather than a way fully to exploit the benefits of NO donor therapy.
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Novel drugs for treating angina.
Jones, DA, Timmis, A, Wragg, A
BMJ (Clinical research ed.). 2013;:f4726
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[Systematic review and meta-analysis of randomized controlled trials comparing Chinese patent medicines Compound Danshen Dripping Pills and Di'ao Xinxuekang in treating angina pectoris].
Ng, CS, Wang, SP, Cheong, JL, Wu, YD, Jia, YL, Leung, SW
Zhong xi yi jie he xue bao = Journal of Chinese integrative medicine. 2012;(1):25-34
Abstract
BACKGROUND Chinese patent medicines Compound Danshen Dripping Pills (DSP) and Di'ao Xinxuekang (DXK) capsules were both found effective in treating angina pectoris. However, there is no systematic review comparing their efficacy. OBJECTIVE This systematic review aims to compare the efficacy of DSP and DXK in treating angina pectoris based on randomized controlled trials (RCTs) comparing their efficacy. SEARCH STRATEGY RCT reports published between 1994 and 2011 were retrieved from databases including China Doctoral Dissertations Full-text Database, Chinese Journal Full-text Database, China Master's Theses Full-text Database, Wanfang Data, Cochrane Library, Excerpts Medica Database, ScienceDirect, MEDLINE (EBSCOhost) and PubMed. The last retrieval was performed on April 7, 2011. INCLUSION CRITERIA RCT reports comparing the effects of DSP and DXK were included, regardless publishing language. DATA EXTRACTION AND ANALYSIS Included RCT reports were assessed for their study quality by using the Jadad scale and the Cochrane risk of bias tool. Data including overall effect and electrocardiography (ECG) improvements were extracted from the included RCTs for meta-analysis. The effect sizes based on overall and ECG diagnosis were measured by odds ratio (OR) and 95% confidence interval (CI). Subgroup analysis and sensitivity analysis were also performed. RESULTS Nine RCT reports with 926 participants were included. Eight were scored 2 and the other one was scored 4 by using the Jadad scale. The OR between DSP and DXK based on overall diagnosis was 2.06 (95% CI: 1.03-4.12; P(overall)=0.04). Six out of the nine included RCTs reported ECG data. The OR between DSP and DXK based on the ECG diagnosis was 1.92 (95% CI: 1.23-3.00; P(ECG)=0.004). The OR results were stable under subgroup analysis and sensitivity analysis. CONCLUSION DSP was consistently more effective than DXK according to meta-analysis, which was verified by subgroup analysis and sensitivity analysis. However, more RCTs of higher quality are needed for further confirmation.