716-4 Placebo Treatment Reduces Both the Number of Ischemic Episodes and Duration of Ambulatory Silent Myocardial ischemia in Patients with Stable Angina Pectoris

Ambulatory silent myocardial ischemia occurs frequently in patients with stable exertional angina pectoris, It is widely accepted that a medication has antiischemic effects if it reduces either the number or the duration of silent myocardial ischemic episodes in comparison to pretreatment values. Effect of monotherapy with placebo on silent myocardial ischemia in 33 patients who took part in a parallel group investigational drug study and were assigned to the placebo arm of the study form the basis of this investigation. After discontinuation of all antianginal medications patients received two weeks of single blind placebo treatment followed by four weeks of double blind placebo treatment. Ambulatory holter monitoring was performed for 48 hours after two weeks of single blind placebo treatment and again after 4 weeks of double blind placebo treatment. The median value of silent myocardial ischemia attack rate during single blind placebo treatment was 7.2 episodes per 48 hours and decreased during double blind placebo treatment to a median rate of 3.1 episodes per 48 hours (P < 0.004; 95% CI, -5.41, -1.0). Similarly the duration of silent myocardial ischemic episodes decreased by a median of 16,1 minutes per 48 hours (P < 0,001; 95% CI. -35.7, -6.2 minutes) during double blind placebo treatment from a median value of 24.8 minutes per 48 hours during single blind placebo treatment.Conclusionplacebo monotherapy had a marked influence on ambulatory silent myocardial ischemia and reduced both the duration and number of silent myocardial ischemic episodes in patients with stable angina pectoris. These findings have important implications for interpretation of studies in which the effects of active treatment on silent myocardial ischemia are compared to baseline pretreatment values

Stable Angina Medical Therapy Management Guidelines: A Critical Review of Guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence

Most patients with stable angina can be managed with lifestyle changes, especially smoking cessation and regular exercise, along with taking antianginal drugs. Randomised controlled trials show that antianginal drugs are equally effective and none of them reduced mortality or the risk of MI, yet guidelines prefer the use of beta-blockers and calcium channel blockers as a first-line treatment. The European Society of Cardiology guidelines for the management of stable coronary artery disease provide classes of recommendation with levels of evidence that are well defined. The National Institute for Health and Care Excellence (NICE) guidelines for the management of stable angina provide guidelines based on cost and effectiveness using the terms first-line and second-line therapy. Both guidelines recommend using low-dose aspirin and statins as disease-modifying agents. The aim of this article is to critically appraise the guidelines’ pharmacological recommendations for managing patients with stable angina

Use of Hydralazine‐Isosorbide Dinitrate Combination in African American and Other Race/Ethnic Group Patients With Heart Failure and Reduced Left Ventricular Ejection Fraction

Background: Hydralazine‐isosorbide dinitrate (H‐ISDN) therapy is recommended for African American patients with moderate to severe heart failure with reduced ejection fraction (<40%) (HFrEF), but use, temporal trends, and clinical characteristics associated with H‐ISDN therapy in clinical practice are unknown. Methods and Results: An observational analysis of 54 622 patients admitted with HFrEF and discharged home from 207 hospitals participating in the Get With The Guidelines–Heart Failure registry from April 2008 to March 2012 was conducted to assess prescription, trends, and predictors of use of H‐ISDN among eligible patients. Among 11 185 African American patients eligible for H‐ISDN therapy, only 2500 (22.4%) received H‐ISDN therapy at discharge. In the overall eligible population, 5115 of 43 498 (12.6%) received H‐ISDN at discharge. Treatment rates increased over the study period from 16% to 24% among African Americans and from 10% to 13% among the entire HFrEF population. In a multivariable model, factors associated with H‐ISDN use among the entire cohort included younger age; male sex; African American/Hispanic ethnicity; and history of diabetes, hypertension, anemia, renal insufficiency, higher systolic blood pressure, and lower heart rate. In African American patients, these factors were similar; in addition, being uninsured was associated with lower use. Conclusions: Overall, few potentially eligible patients with HFrEF are treated with H‐ISDN, and among African‐Americans fewer than one‐fourth of eligible patients received guideline‐recommended H‐ISDN therapy. Improved ways to facilitate use of H‐ISDN therapy in African American patients with HFrEF are needed

A Randomized, Double-Blind, Placebo-Controlled, Crossover, Dose-Ranging Multicenter Study to Determine the Effect of Sublingual Nitroglycerin Spray on Exercise Capacity in Patients with Chronic Stable Angina

Background Sublingual nitroglycerin increases exercise duration in patients with stable angina. Brief results from this study were published previously in German. Here, we more fully describe the study methodology, patient characteristics, and detailed results. Methods This double-blind, crossover study enrolled 51 patients with stable angina. Patients were randomized to 1 of 5 treatment sequences and were administered placebo or nitroglycerin spray (0.2 mg, 0.4 mg, 0.8 mg, or 1.6 mg). Patients carried out 1 control exercise tolerance test (ETT) and 1 investigational ETT at each visit. Results Dose-dependent increases in time to onset of angina, time to onset of moderate angina, and the occurrence of a minimum 1.0-mm ST-segment depression were seen following administration of nitroglycerin spray. Conclusions These results support the use of sublingual nitroglycerin spray in patients with stable angina who are being managed with medical therapy and in patients who have persistent angina post-revascularization