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Indian Heart J. 2017 Jan-Feb; 69(1): 129–132.
Published online 2017 February 2. doi:  10.1016/j.ihj.2017.01.004
PMCID: PMC5319125

Re chronic stable angina guidelines

Dear Dr Mishra,

I read with interest your new guidelines on Chronic stable angina.1

I feel one or two things should be added the guidelines.

  • 1.
    The type of chest pain is very important. Just as the ACC guidelines say a chest pain that worsens on emotion or exertion and is relieved at rest is likely to be a cardiac pain. This should be emphasized. The duration of the chest pain is also important. We should emphasize a 1 or 2 s chest pain localized with a finger tip is not a cardiac pain.2
  • 2.
    The second point is – any new onset angina should be treated with loading with clopidogrel as it acts within 2 h and reduces cardiovascular mortality. So we should include clopidogrel in the guidelines.4 When clopidogrel is given as 75 mg daily it takes 5–7 days to achieve optimum platelet inhibition. Both the Cure trial and the PCI-Cure trials have shown that clopidogrel reduces the total cardiovascular mortality significantly.5, 6
  • 3.
    Statins like atorvastatin should be given at the 40 mg dose.7 In STEMI patients loading with statin 80 mg atorvastatin and continuing 40 mg statin(atorvastatin) has been shown to reduce the following inflammatory markers-high sensitivity CRP,BNP and MMP 9 high-sensitivity C-reactive protein (hs-CRP), B-type natriuretic peptide (BNP), and matrix metalloproteinase type 9 (MMP-9) (P < 0.05). The ejection fraction of these patients also increased better than in those given low dose statins.
  • 4.
    I feel stenting for simple left main coronary artery disease is better than CABG because there is no time delay (Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6). I find left main patients sometimes die even before they can go for surgery. So I feel if they have a low syntax score,in India we should recommend early PCI even as a class 1 indication.
    Fig. 1
    The coronary angiogram of a patient with chronic stable angina. Her age was 47 years. (Proximal left main stenosis of 80%).
    Fig. 2
    Another angiographic view of the same patient.
    Fig. 3
    Her electrocardiogram before angiogram.
    Fig. 4
    Her electrocardiogram 4 h after angiogram showing multiple ST depressions.
    Fig. 5
    Her angiogram after intervention,she was stented with a 4 × 23 Science Prime stent,Post dilatation was done and ostial flaring was also done.
    Fig. 6
    The stent seen after intervention.

We have had numerous patients who survived after left main stenting and did not have repeat events. I would like to show the electrocardiograms and angiographic pictures of one such patient (Fig. 1, Fig. 2, Fig. 3, Fig. 4). She had chronic stable angina .She became unstable after 4 h after the angiogram and the stenting was done at ll pm and finished at 1 am (Fig. 5, Fig. 6). She survived and still comes for follow-up. She did not have adequate finances to send for emergency CABG.

Other wise the guideline is quite adequate.

Thanking you,

References

1. Mishra S., Ray S., Dalal J.J. Management standards for stable coronary disease in India. Indian Heart J. 2016;68:S31–S49. [PubMed]
2. Anderson J.L., Adams C.D., Antman E.M. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction “A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007;116:e148–e304. [PubMed]
4. Savcic M., Hauert J., Bachmann F. Clopidogrel loading dose regimens: kinetic profile of pharmacodynamics response in healthy subjects. Semin Thromb Hemost. 1999;25(Suppl. 2):15–19. [PubMed]
5. Mehta S.R., Yusuf S. The Clopidogrel in Unstable angina to prevent Recurrent Events(CURE) trial programme; rationale, design and baseline characteristics including a meta-analysis of the effects of thienopyridines in vascular disease. Eur Heart J. 2000;24:2033–2041. [PubMed]
6. Mehta S.R., Yusuf S., Peters R.J.G. Effects of pre-treatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet. 2001;358:527–533. [PubMed]
7. Liu H.L., Yang Y., Yang S.L. Administration of a loading dose of atorvastatin before percutaneous coronary intervention prevents inflammation and reduces myocardial injury in STEMI patients: a randomized clinical study. Clin Ther. 2013;35(March):261–272. http://dx.doi.org/10.1016/j.clinthera.2013.01.009. Accessed on 3 January 2017. [PubMed]

Further reading

S.D. Fihn , J.C. Blankenship , K.P. Alexander , et al. ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease Circulation 2014; 130: 1749-1767 . doi:10.1161/CIR.0000000000000095


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