Number 24, 2004
Angina Pectoris

What's new in angina pectoris?

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Frans C. Visser
Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands
Correspondence: Prof Frans Visser, Department of Cardiology, Academic Hospital Vrije Universiteit, De Boelalaan 1117, 1081 HV Amsterdam, The Netherlands.
Tel: 31 20444 44 44, fax: 31 20444 24 46, e-mail: fc.visser@azvu.nl

The characteristics of the clinical syndrome chronic stable angina pectoris is very well known. Epidemiological data show that a very large number of persons are afflicted [1], especially in western societies. Risk factors for developing coronary artery disease [2] and, once angina pectoris is present, for development of cardiac events, have been well documented [3]. For the diagnosis of coronary artery disease quite a few diagnostic tests are available, both invasive and noninvasive. The noninvasive tests are in general based on demonstration of ECG, wall motion, and perfusion abnormalities and all have their merits in terms of diagnostic accuracy and cost effectiveness [4]. Although angiography as gold standard for the diagnosis of coronary artery disease can be debated, it is still the method of choice when considering bypass surgery (CABG) or a percutaneous intervention (PCI) in a patient.
In general, treatment principles are simple: apart from preventive therapy and lifestyle modification, chronic stable angina patients are treated with pharmacological agents that reduce the supply-demand imbalance and thereby reduce symptoms and improve quality of life. If patients have symptoms despite pharmacological therapy, revascularization may be performed. Finally, prognosis is well known. Not surprisingly, many excellent reviews and guidelines are available in the literature [5, 6].
So, if there is nothing new, why devote an issue of Heart and Metabolism to this subject? First of all, let's think about the term chronic stable angina. My opinion is that chronic stable angina is not a stable disease: data show that annual mortality is 1.6% to 3.2% [3]. Apart from these mortality figures, a multiple of this number of patients is admitted to hospital because of complications like infarction, unstable angina, urgent revascularization, progression to heart failure, etc. Therefore, this is not a stable disease affecting a substantial portion of patients. Second, it has major socioeconomic effects: because the general population gets older, it is to be expected that the total number of coronary artery disease patients will increase rapidly. Medication will be life-long, and the number of patients undergoing re-PCIs or CABG “redos” will increase. In this respect, a previous issue of Heart and Metabolism was devoted to “focus on the elderly”[7]. It is worthwhile reading it again (also available at www.heartandmetabolism.org). Another worrying aspect is refractory angina, defined as severe disabling angina in spite of optimal medical therapy, where revascularization is not feasible. In Issue 16 of Heart and Metabolism (Refractory angina) M.R. Chester states in his summary: all the available evidence indicates that the size of the chronic refractory angina population will grow inexorably to present a major clinical problem within a decade [8]. In summary, these are reasons enough to discuss some clinical problems associated with angina pectoris.
The nature of ischemic pain perception is not well known by clinicians, and Filippo Crea explains very clearly in the Basic Article the various components of pain perception. An important issue on the management of stable angina pectoris is discussed by Mario Marzilli in the Main Clinical Article. In view of the fact that we have accurate techniques available to detect the impact of the ischemia on the heart and also that stable angina is associated with significant mortality and morbidity, it no longer suffices to treat all angina patients in a similar manner. An important issue is risk stratification: to stratify patients into those with a high and a low risk for future coronary events. Needless to say high-risk patients need more aggressive management than low-risk patients.
One of the fascinating new developments is the noninvasive imaging of the coronary arteries. Nico Mollet and coworkers will show in the Imaging section the potential of CT imaging for this purpose. In the Refresher Corner a similar topic is discussed by Gerald Werner: the collateral circulation. I had the feeling that collateral circulation was something everybody talked about, but nobody knew what it really was. Using new techniques, collateral circulation can now be quantified, which opens the way to further understanding and possibly to new therapeutic interventions.
In New Therapeutic Approaches Pieter van Zwieten discusses the fine-tuning of current pharmacotherapy for the treatment of angina and shows the potential advantages of drugs other than β-blockers, calcium-antagonists, and nitrates. In Focus on Vastarel, G Rosano elaborates on the safety of antianginal drugs in combination with phosphodiesterase type 5 (PDE5) inhibitors, indicating that switching from nitrates to trimetazidine is safe in patients with coronary artery disease requiring treatment with PDE5-inhibitors. Finally, not everything is coronary artery disease related. We present in the Case Report a patient with ECG changes and LV dysfunction due to cerebral bleeding.
In short, this issue presents many new aspects on chronic stable angina pectoris. Enjoy reading.▪

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REFERENCES

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