Manual therapy for patients with stable angina pectoris: a nonrandomized open prospective trial.

OBJECTIVE: To examine if participants with chest pain originating from the spine would benefit from manual therapy. METHODS: A nonrandomized, open, prospective trial was performed at a tertiary hospital. Patients who were referred for coronary angiography because of known or suspected stable angina pectoris were invited to participate in this study. A total of 275 took part, 50 were diagnosed as cervicothoracic angina (CTA)-positive (chest pain from the cervicothoracic spine) and 225 as CTA-negative. The intervention performed was manual therapy according to chiropractic standards. Patient self reported questionnaires at baseline and 4-week follow-up, including pain measured with an 11-point box scale, Short Form 36 (quality of life), and perceived improvement. RESULTS: Approximately 75% of CTA-positive patients reported improvement of pain and of general health after treatment, compared with 22% to 25% of CTA-negative patients (P < .0001). Pain intensity decreased in both groups with consistently larger decreases for all measures of pain among CTA-positive patients. Short Form 36 scores increased in the CTA-positive group in 5 of 8 scales and remained unchanged in the CTA-negative group. CONCLUSION: This study suggested that patients with known or suspected angina pectoris and a diagnosis of CTA may benefit from chiropractic manual therapy. Methodologically, sound randomized clinical trials are needed to corroborate our results.

Management options for angina refractory to maximal medical and surgical interventions.

Despite the seemingly daily advances in the primary, secondary, and tertiary prevention for coronary artery disease, many patients will ultimately experience progression of their disease and experience angina refractory to further active treatment. In these patients, disabling angina occurs at rest or during simple activities of daily living. When this occurs, symptom management, a predominant focus of nursing, becomes the goal of care. Several medical and surgical alternatives are available to patients with refractory angina. Enhanced external counterpulsation and transmyocardial laser revascularization are Food and Drug Administration approved therapies that can be used to attempt to restore the balance of supply and demand. Modulation of sympathetic tone via procedures such as stellate ganglion blocks has also been employed. Other methods to control the pain are techniques that alter pain perception such as spinal opioids, transcutaneous electrical nerve stimulation, and spinal cord stimulation. Too few patients with refractory angina are referred for any of these palliative therapies. Armed with knowledge regarding these therapies, nurses will be better prepared to provide anticipatory guidance to patients and their families and to support the patient's hope for relief as they cope with this devastating condition.

Electrophysiologic properties and antiarrhythmic actions of a novel antianginal agent.

Ranolazine is a novel antianginal agent capable of producing anti-ischemic effects at plasma concentrations of 2 to 6 microM without a significant reduction of heart rate or blood pressure. This review summarizes the electrophysiologic properties of ranolazine. Ranolazine significantly blocks I(Kr) (IC(50) = 12 microM), late I(Na), late I(Ca), peak I(Ca), I(Na-Ca) (IC(50) = 5.9, 50, 296, and 91 microM, respectively) and I(Ks) (17% at 30 microM), but causes little or no inhibition of I(to) or I(K1). In left ventricular tissue and wedge preparations, ranolazine produces a concentration-dependent prolongation of action potential duration (APD) in epicardium, but abbreviation of APD of M cells, leading to either no change or a reduction in transmural dispersion of repolarization (TDR). The result is a modest prolongation of the QT interval. Prolongation of APD and QT by ranolazine is fundamentally different from that of other drugs that block I(Kr) and induce torsade de pointes in that APD prolongation is rate-independent (ie, does not display reverse rate-dependent prolongation of APD) and is not associated with early after depolarizations, triggered activity, increased spatial dispersion of repolarization, or polymorphic ventricular tachycardia. Torsade de pointes arrhythmias were not observed spontaneously nor could they be induced with programmed electrical stimulation in the presence of ranolazine at concentrations as high as 100 microM. Indeed, ranolazine was found to possess significant antiarrhythmic activity, acting to suppress the arrhythmogenic effects of other QT-prolonging drugs. Ranolazine produces ion channel effects similar to those observed after chronic exposure to amiodarone (reduced late I(Na), I(Kr), I(Ks), and I(Ca)). Ranolazine's actions to reduce TDR and suppress early after depolarization suggest that in addition to its anti-anginal actions, the drug possesses antiarrhythmic activity.

[Characteristics of traditional Chinese medicine syndromes in both spontaneous and variant angina. An analysis of 21 cases].

An analysis of TCM syndromes is reported in 21 cases with both spontaneous and variant angina as compared with 147 cases with effort angina. The results showed that 3 characteristic features were present, which were as follows: the Biao-Shi syndrome of cold condensation was more than that of the control group in ratio of 42.86% to 3.40%; the Ben-Xu syndrome of Yang deficiency was more and that of Qi deficiency less than those in the control group, and they were in ratio of 33.33% to 6.12% and 33.33% to 72.11% respectively. An absolute reduction of blood supply resulted from coronary spontaneous spasm in both spontaneous and variant angina causes severe chest pain during attacks as a cold condensation type. Hyperfunction of parasympathetic nerves often occurring in coronary heart disease with Yang deficiency is liable to vasoconstriction of the large coronary arteries leading to episodes of both spontaneous and variant angina. The presence of less Qi deficiency type may be related to the less impairment of cardiac function resulted from the short course in these cases and only relatively mild state of an illness, even no marked lesion in coronary arteries in a part of patients with both spontaneous and variant angina. No significant difference in TCM syndromes occurred between spontaneous and variant angina. Both Yang and Yin deficiency, as the Ben-Xu syndromes, were more present in angina of cold condensation type.(ABSTRACT TRUNCATED AT 250 WORDS)

Transient myocardial ischemia during daily life in rest and exertional angina pectoris and comparison of effectiveness of metoprolol versus nifedipine.

The clinical characteristics of 65 patients with mixed angina were classified by means of (1) a questionnaire investigating the proportion of symptoms occurring at rest and on effort, (2) an exercise stress test, (3) 24-hour ambulatory Holter monitoring, and (4) coronary arteriography. According to the questionnaire, the proportion of effort-induced anginal episodes ranged from 1 to 99%. The ischemic threshold during exercise testing ranged from 110 x 10(2) to 350 x 10(2) mm Hg x beats/min. At least 1 episode of ST-segment depression was observed in 29 of the 65 patients during Holter monitoring. Ischemic episodes during Holter monitoring were more frequent (p less than 0.05) in patients reporting greater than or equal to 50% of anginal attacks on effort, with moderate to severe limitation of exercise capacity and with multivessel coronary artery disease. The effect on ambulatory ischemia of a 6-week treatment with a beta blocker (metoprolol CR, 200 mg once daily) or a dihydropyridine calcium antagonist (nifedipine retard 20 mg twice daily) were then compared according to a double-blind, parallel group design. Metoprolol significantly reduced the number and duration of the ischemic episodes during daily life (p less than 0.05) irrespective of the patients' clinical characteristics. Nifedipine was ineffective, particularly in patients with angina predominantly on effort and with a moderate to severe reduction in exercise tolerance. It is concluded that in patients with mixed angina, ischemic episodes during daily life are more likely to occur in patients with a clinical presentation suggesting poor coronary reserve.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid sinus reflex in patients undergoing coronary angiography: relationship of degree and location of coronary artery disease to response to carotid sinus massage.

Heart rate and blood pressure responses during and after carotid sinus massage were examined in 66 patients just before coronary angiography. A significant relationship was found between heart rate and blood pressure responses and (1) angina pectoris class, (2) total coronary artery disease score and (3) presence of high-grade (> 90%) stenosis of any of the three major coronary arteries. Only patients with contraction abnormalities of the anterolateral left ventricular region had greater cardionhibitory responses than patients with normal left ventricular angiograms. Among patients with normal left ventricular angiograms, those with more than 50% stenosis of one or more vessels had significantly (p < 0.01) greater responses than those with no or minimal coronary artery disease. All 21 hypersensitive (asystole longer than 3 seconds) patients had significant multivessel coronary artery stenoses or single-vessel high-grade stenosis (greater than or equal to 90%) proximal to the atrioventricular nodal artery. None of the 11 patients with normal coronary arteries had an exaggerated response to carotid sinus massage. These data support the association of an exaggerated response to carotid sinus massage in the presence of symptomatic coronary artery disease and suggest that the magnitude of response is influenced by the severity of the disease.

Historia natural de la cardiopatía coronaria y sus implicaciones profilácticas, pronósticas y terapeúticas / Natural history of the coronary cardiopathy and its prophylactic, prognostic and therapeutic implications

Creemos haber demostrado que en la actualidad no es razonable hablar de la evolución natural de la cardioapatía isquémica en su conjunto. Es posible identificar una serie de cuadros clínicos con diferentes modalidades evolutivas que confirmen características determinadas a cada uno de los grupos. Lo antedicho avala la propuesta de nuestra clasificación de la cardiapatía isquémica sintomática en base al angor, esta división es sin duda perfectible pero, hemos comenzado a aplicarla hace cuatro años y hasta ahora funciona a entera satisfacción. Todavía hoy se lee y se escucha en los congresos nacionales e internacionales que muy poco se conoce de la evolución natural de la ateroesclerosis coronaria en la angina de pecho estable. Es indudable que mucho se ha progresado en el conocimiento de la misma desde los trabajos iniciales analizados aquí y basados solamente en la clasificación clínica de los pacientes, con todos los errores que ello llevaba involucrado. No obstante dieron una idea general del panorama a abarcar y en nuestros días la introducción de la cine coronario angiografía por Sones abrió todo un camino para conocer la base anatómica precisa de la enfermedad... (TRUNCADO)

Historia natural de la cardiopatía coronaria y sus implicaciones profilácticas, pronósticas y terapeúticas / Natural history of the coronary cardiopathy and its prophylactic, prognostic and therapeutic implications

Creemos haber demostrado que en la actualidad no es razonable hablar de la evolución natural de la cardioapatía isquémica en su conjunto. Es posible identificar una serie de cuadros clínicos con diferentes modalidades evolutivas que confirmen características determinadas a cada uno de los grupos. Lo antedicho avala la propuesta de nuestra clasificación de la cardiapatía isquémica sintomática en base al angor, esta división es sin duda perfectible pero, hemos comenzado a aplicarla hace cuatro años y hasta ahora funciona a entera satisfacción. Todavía hoy se lee y se escucha en los congresos nacionales e internacionales que muy poco se conoce de la evolución natural de la ateroesclerosis coronaria en la angina de pecho estable. Es indudable que mucho se ha progresado en el conocimiento de la misma desde los trabajos iniciales analizados aquí y basados solamente en la clasificación clínica de los pacientes, con todos los errores que ello llevaba involucrado. No obstante dieron una idea general del panorama a abarcar y en nuestros días la introducción de la cine coronario angiografía por Sones abrió todo un camino para conocer la base anatómica precisa de la enfermedad... (TRUNCADO)(AU)