Improving the quality of life for patients with angina pectoris: a team approach to disease management.

The evaluation of outcome of management of angina patients is now inextricably linked with an assessment of quality of life. Angina, as a manifestation of coronary heart disease, is a major cause of morbidity and mortality in many countries. Optimal management of patients with angina is of undeniable national and global significance.

This paper attempts to indicate the importance of a team approach and the implications for patients’ quality of life of involving professionals with a variety of different skills. It outlines current guidelines for the management of angina, including aspects of diagnosis, treatment and rehabilitation. Factors of relevance to the management of patients as individuals are discussed. The association of improved quality of life and reduced severity of symptoms with benefit for both the individual and society is considered.

Doença periodontal e angina pectoris estável: um estudo caso-controle

The search which it aim was to analyze the Periodontal Disease as a risk factor for the development of the Stable Angina Pectoris. For that, 120 patients (52 blokes and 68 wenches ), ages ranging from 40 to 65 years old, and attended to the Hemodinamic´s Sector of the Natal Hospital Center, showing the historic of Angina Pectoris to accomplishment of cinecoronariografhy. Before the accomplishment of this exam, the patients were submitted to interview, to investigate the possible risk factors for the Cardiovascular diseases , and it was followed of clinical periodontal examination to evaluate the presence of Periodontal Disease. After the cinecoronariography, the patients who presented diagnosis of important arterial obstruction (above 70%) were enrolled to the case grup. However the individuals with arteries free of obstruction, or obstrution below 30%, were considered without historic of Cardiovascular disease and therefore enrolled for the control grup. The groups were paired by the variables age and gender. From the analysis of the results, a did not observed statisticment the significant association between the presence of the Periodontal Disease, probing depth, periodontal attachment level, severity and extension index of the Periodontal Disease, besides the visible plaque index (VPI) an gingival bleeding index (GBI) regarding to the existence of Stable Angina Pectoris. Nevertheless , it was identified statisticment the significant association between the sistemic arterial hypertension , seric level of total cholesterol, LDL, HDL and triglycerides, showing all of them, classic risk factors appointed by the literature. Therefore, it was conclued that Periodontal Disease did not represent association with the StableAngina Pectoris at least among the studied population

Percutaneous coronary revascularization in patients with formerly "refractory angina pectoris in end-stage coronary artery disease" - not "end-stage" after all

BACKGROUND: Patients with refractory angina pectoris in end-stage coronary artery disease represent a severe condition with a higher reduction of life-expectancy and quality of life as compared to patients with stable coronary artery disease. It was the purpose of this study to invasively re-evaluate highly symptomatic patients with formerly diagnosed refractory angina pectoris in end-stage coronary artery disease for feasible options of myocardial revascularization. METHODS: Thirty-four patients formerly characterized as having end stage coronary artery disease with refractory angina pectoris were retrospectively followed for coronary interventions. RESULTS: Of those 34 patients 21 (61.8%) were eventually revascularized with percutaneous interventional revascularization (PCI). Due to complex coronary morphology (angulation, chronic total occlusion) PCI demanded an above-average amount of time (66 +/- 42 minutes, range 25-206 minutes) and materials (contrast media 247 +/- 209 ml, range 50-750 ml; PCI guiding wires 2.0 +/- 1.4, range 1-6 wires). Of PCI patients 7 (33.3%) showed a new lesion as a sign of progression of atherosclerosis. Clinical success rate with a reduction to angina class II or lower was 71.4% at 30 days. Surgery was performed in a total of8 (23.5%) patients with a clinical success rate of 62.5%. Based on an intention-to-treat 2 patients of originally 8 (25%) demonstrated clinical success. Mortality during follow-up (1-18 months) was 4.8% in patients who underwent PCI, 25% in patients treated surgically and 25% in those only treated medically. CONCLUSION: The majority of patients with end-stage coronary artery disease can be treated effectively with conventional invasive treatment modalities. Therefore even though it is challenging and demanding PCI should be considered as a first choice before experimental interventions are considered.

Cardiac Shock Wave Therapy for Chronic Refractory Angina Pectoris. A Prospective Placebo-Controlled Randomized Trial

Background: Cardiac shock wave therapy (CSWT) delivered to the myocardium increases capillary density and regional myocardial blood flow in animal experiments. In addition, nonenzymatic nitric oxide production and the upregulation of vascular growth factor's mRNA by CSWT have been described. The aim of the study was therefore to test its potential to relieve symptoms in patients with chronic stable angina pectoris. Methods: Twenty-one patients (mean age 68.2 ± 8.3 years, 19 males) with chronic refractory angina pectoris and evidence of inducible myocardial ischemia during MIBI-SPECT imaging, were randomized into a treatment (n = 11) and a placebo arm (n = 10). The region of exercise-induced ischemia was treated with echocardiographic guidance during nine sessions over a period of 3 months. One session of CSWT consisted of 200 shots/spot (9--12 spots/session) with an energy intensity of 0.09 mJ/mm2. In the control group acoustic simulation was performed without energy application. Medication was kept unchanged during the whole treatment period. Results: In the treatment group, symptoms improved in 9/11 patients, and the ischemic threshold, determined by cardiopulmonary exercise stress testing, increased from 80 ± 28 to 95 ± 28 W (P= 0.036). In the placebo arm, only 2/10 patients reported an improvement and the ischemic threshold remained unchanged (98 ± 23 to 107 ± 23 W; P= 0.141). The items “physical functioning” (P= 0.043), “general health perception” (P= 0.046), and “vitality” (P= 0.035) of the SF-36 questionnaire significantly improved in the treatment arm, whereas in the placebo arm, no significant change was noted. Neither arrhythmias, troponin rise nor complications were observed during treatment. Conclusions: This placebo controlled trial shows a significant improvement in symptoms, quality of life parameters and ischemic threshold during exercise in patients with chronic refractory angina pectoris treated with CSWT. Thus, CSWT represents a new option for the treatment of patients with refractory AP.

Impact of Clinical Presentation (Stable Angina Pectoris vs Unstable Angina Pectoris or Non-ST-Elevation Myocardial Infarction vs ST-Elevation Myocardial Infarction) on Long-Term Outcomes in Women Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents

The long-term risk associated with different coronary artery disease (CAD) presentations in women undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is poorly characterized. We pooled patient-level data for women enrolled in 26 randomized clinical trials. Of 11,577 women included in the pooled database, 10,133 with known clinical presentation received a DES. Of them, 5,760 (57%) had stable angina pectoris (SAP), 3,594 (35%) had unstable angina pectoris (UAP) or non-ST-segment-elevation myocardial infarction (NSTEMI), and 779 (8%) had ST-segment-elevation myocardial infarction (STEMI) as clinical presentation. A stepwise increase in 3-year crude cumulative mortality was observed in the transition from SAP to STEMI (4.9% vs 6.1% vs 9.4%; p <0.01). Conversely, no differences in crude mortality rates were observed between 1 and 3 years across clinical presentations. After multivariable adjustment, STEMI was independently associated with greater risk of 3-year mortality (hazard ratio [HR] 3.45; 95% confidence interval [CI] 1.99 to 5.98; p <0.01), whereas no differences were observed between UAP or NSTEMI and SAP (HR 0.99; 95% CI 0.73 to 1.34; p = 0.94). In women with ACS, use of new-generation DES was associated with reduced risk of major adverse cardiac events (HR 0.58; 95% CI 0.34 to 0.98). The magnitude and direction of the effect with new-generation DES was uniform between women with or without ACS (pinteraction = 0.66). In conclusion, in women across the clinical spectrum of CAD, STEMI was associated with a greater risk of long-term mortality. Conversely, the adjusted risk of mortality between UAP or NSTEMI and SAP was similar. New-generation DESs provide improved long-term clinical outcomes irrespective of the clinical presentation in women.

Impacto clínico e econômico da redefinição dos critérios diagnósticos de infarto do miocárdio

Introdução: Estudos sobre implicações clínicas da nova definição de infarto do miocárdio (IAM), incorporando novos marcadores de lesão miocárdica, são escassos na literatura. A prevalência de IAM e das suas complicações são diretamente dependentes do critério diagnóstico utilizado. Objetivo: Avaliar o impacto diagnóstico, prognóstico e econômico da nova definição de IAM proposta pela AHA/ ESC usando troponina T (TnT) como marcador de lesão cardíaca. Métodos: Um total de 740 pacientes com dor torácica admitidos na Emergência do Hospital de Clínicas de Porto Alegre no período de julho/ 1999 a janeiro/ 2002 foram incluídos no estudo. Creatina quinase total (CK), CK-MB atividade e TnT foram dosados em uma amostra de 363 pacientes, representativa de toda a coorte. Para redefinição de IAM foram utilizados como ponto de corte valores pico de TnT > 0,2 mg/dl. Os desfechos avaliados foram classificados como eventos cardíacos maiores (angina recorrente, insuficiência cardíaca congestiva, choque cardiogênico e óbito) e como procedimentos de revascularização. Também foram avaliados o manejo prescrito, os custos e o faturamento hospitalar. Resultados: Nos 363 pacientes com marcadores dosados, foram diagnosticados 59 casos de IAM (16%) pelos critérios clássicos; enquanto 40 pacientes (11%) tiveram o diagnóstico de IAM pelo critério redefinido, o que corresponde a um incremento de 71% na incidência. Pacientes com IAM redefinido eram significativamente mais idosos e do sexo masculino, apresentaram mais dor atípica e diabetes mellitus. Na análise multivariada, pacientes com infarto redefinido tiveram um risco 5,1 [IC 95% 1,0-28] vezes maior para óbito hospitalar e 3,4 [IC 95% 1,1-10] vezes maior para eventos combinados em relação aqueles sem IAM. O manejo dos casos de IAM redefinido foi semelhante ao manejo daqueles com IAM tradicional, exceto pelos procedimentos de revascularização que foram menos freqüentes (25% vs. 51%, P < 0,001). O grupo com IAM redefinido permaneceu mais tempo internado e foi submetido a procedimentos mais tardiamente. Do ponto de vista institucional, o uso dos novos critérios para IAM poderia resultar em um aumento de 9% (mais R$ 2.756,00 por grupo de 100 pacientes avaliados) no faturamento baseado em diagnóstico segundo a tabela do SUS. Conclusões: O novo diagnóstico de IAM acrescenta um número expressivo de indivíduos com infarto aos serviços de emergência. A incorporação deste critério é importante na medida que estes pacientes têm um prognóstico semelhante aos demais casos tradicionalmente diagnosticados. Como a identificação destes casos poderia resultar em um manejo mais qualificado e eficiente destes pacientes, esforços deveriam ser adotados para reforçar a adoção da redefinição de IAM.

Using the Rose Angina Questionnaire cross-culturally : the importance of consulting lay people when translating epidemiological questionnaires

Objectives. The Rose Angina Questionnaire (RAQ) is an important measure of coronary heart disease prevalence. It has been shown to perform inconsistently across some ethnic groups in Britain. This study investigates whether the best available versions of the RAQ in Punjabi and Cantonese were linguistically equivalent to the English version.

Design. Interviews were carried out with lay people from the Pakistani, Chinese and European-origin communities in Scotland to assess the versions of the RAQ used in the Newcastle Heart Project (the best available versions). For each questionnaire item, participants were asked to elaborate on their understanding of the question and the meaning of keywords or phrases.

Results. Problems were discovered with the Punjabi and Cantonese translations of the RAQ. For example, the translation for ‘chest’ was interpreted by some Pakistani and Chinese women to mean ‘breasts’. ‘Walking uphill’ was translated in Chinese as ‘walking the hill’, without stipulation of the direction, so that some Cantonese speakers interpreted the question as pertaining to walking downhill. Many Chinese interpreted RAQ items to be referring to breathlessness rather than chest pain due to ambiguous wording.

Conclusion. Existing versions of the RAQ are unlikely to be yielding data that are cross-culturally valid or comparable. For robust health survey research in languages other than that in which the questionnaire was developed, lay assessment of questionnaires prior to and after translation is a necessity rather than a luxury.

Sensitivity, specificity and predictive values of linear and nonlinear indices of heart rate variability in stable angina patients

Background: Decreased heart rate variability (HRV) is related to higher morbidity and mortality. In this study we evaluated the linear and nonlinear indices of the HRV in stable angina patients submitted to coronary angiography. Methods. We studied 77 unselected patients for elective coronary angiography, which were divided into two groups: coronary artery disease (CAD) and non-CAD groups. For analysis of HRV indices, HRV was recorded beat by beat with the volunteers in the supine position for 40 minutes. We analyzed the linear indices in the time (SDNN [standard deviation of normal to normal], NN50 [total number of adjacent RR intervals with a difference of duration greater than 50ms] and RMSSD [root-mean square of differences]) and frequency domains ultra-low frequency (ULF) ≤ 0,003 Hz, very low frequency (VLF) 0,003 - 0,04 Hz, low frequency (LF) (0.04-0.15 Hz), and high frequency (HF) (0.15-0.40 Hz) as well as the ratio between LF and HF components (LF/HF). In relation to the nonlinear indices we evaluated SD1, SD2, SD1/SD2, approximate entropy (-ApEn), α1, α2, Lyapunov Exponent, Hurst Exponent, autocorrelation and dimension correlation. The definition of the cutoff point of the variables for predictive tests was obtained by the Receiver Operating Characteristic curve (ROC). The area under the ROC curve was calculated by the extended trapezoidal rule, assuming as relevant areas under the curve ≥ 0.650. Results: Coronary arterial disease patients presented reduced values of SDNN, RMSSD, NN50, HF, SD1, SD2 and -ApEn. HF ≤ 66 ms§ssup§2§esup§, RMSSD ≤ 23.9 ms, ApEn ≤-0.296 and NN50 ≤ 16 presented the best discriminatory power for the presence of significant coronary obstruction. Conclusion: We suggest the use of Heart Rate Variability Analysis in linear and nonlinear domains, for prognostic purposes in patients with stable angina pectoris, in view of their overall impairment. © 2012 Pivatelli et al.; licensee BioMed Central Ltd.

Validation of the Short-Version of Rose Angina Questionnaire in Brazil

Background: Stable angina pectoris is a serious condition with few epidemiological studies in Brazil. Objective: To validate the short-version of the Rose angina questionnaire in Brazilian Portuguese for its implementation in surveys and longitudinal studies. Methods: A total of 116 consecutive patients from an outpatient clinic without prior myocardial infarction and/or coronary revascularization were enrolled for application of three questions of the Rose angina questionnaire addressing chest pain after exertion. We used the treadmill test as the gold standard with the Ellestad protocol. Results: The short-version of the Rose angina questionnaire of the 116 subjects submitted to the exercise treadmill test disclosed 89.7% of accuracy, 25% of sensitivity, 92.0% of specificity, 10.0% of positive predictive value, 97.2% of negative predictive value, and 3.1 of positive likelihood ratio and 0.82 of negative likelihood ratio. Conclusion: The Portuguese version with three items of the Rose angina questionnaire is suitable for epidemiological purposes. (Arq Bras Cardiol 2012; 99(5): 1056-1059)