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Angina pectoris: interventional therapies and treatment of restenosis

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Abstract

Angina pectoris is a clinical syndrome of symptoms caused by myocardial ischaemia due to oxygen demand exceeding supply. The most common cause is coronary artery stenosis due to progressive atherosclerotic disease. Angina has a prevalence of approximately 5% and increases with age. Despite improvements in treatment there remains a yearly mortality of 2–3%. A major advance in the treatment of symptomatic angina was the introduction of percutaneous transluminal coronary angioplasty (PTCA). This initial enthusiasm was dampened by significant numbers developing symptomatic restenosis from vascular elastic recoil and neointimal hyperplasia (NI). The widespread introduction of stent deployment following the initial angioplasty reduced the rates of elastic recoil but failed to prevent NI and may actually stimulate it. Currently, there is much interest in mechanisms that alter cell proliferation thereby decreasing NI. Techniques include brachytherapy, photodynamic therapy and drug-eluting stents. Provisional data for these new stents, which slowly release medication that inhibits cell turnover, are very good with few occurrences of restenosis. Results from larger randomised trials are awaited.

Introduction

Angina is a clinical syndrome consisting of pain, discomfort, and heaviness of the chest, arm or jaw. It is precipitated by exercise, emotional stress and anxiety and is relieved by rest and or administration of glyceryl trinitrate. The symptoms usually last for a few minutes and are caused by myocardial ischaemia of severity and duration insufficient to cause myocardial cell necrosis. The ischaemia occurs when myocardial blood flow is insufficient for myocardial oxygen demand. Most usually this is because of coronary artery narrowing due to atherosclerosis.

Initial treatment for angina involves modification and treatment of underlying risk factors. Adequate time must be spent educating patients regarding their lifestyle and the effect it has on their disease. Additional medication may be required for optimum control of risk factors (diabetes, hypertension, hypercholesterolaemia).

Treatment can then be divided into symptomatic including, beta blockers, nitrate preparations, calcium channel antagonists, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass grafting (CABG) and prognostic, including aspirin, lipid lowering agents such as statins, coronary artery bypass grafting and in recent studies, nicorandil (The IONA Study group, 2002), and angiotensin converting enzyme inhibitors (ACE inhibitors) (The Heart Outcomes Prevention Evaluation Study Investigators, 2000). The latter appear to have disease modifying effects which make them particularly beneficial in patients with hypertension or diabetes.

Occlusive disease of coronary arteries, whether from atheroma or thrombosis, may be treated with percutaneous endovascular intervention, which restores patency without the need for major surgical reconstruction. In the UK in 1998/1999 there were more than 21,000 (Gray & Callum, 2002) such procedures and this figure has increased over time such that use of the technique has now exceeded that of coronary artery bypass grafting.

Section snippets

Coronary angiography

This remains the gold standard for diagnosis of coronary artery disease. It involves insertion of a catheter into the heart via a cannula inserted in a distal artery. Under fluoroscopic guidance specific catheters are manipulated into the coronary ostia, where 5–10 ml of contrast is injected. Several images in different planes are taken of the left and right coronary arteries. The contrast delineates the coronary arteries and on X-ray screening demonstrates any occlusion or significant stenosis.

Percutaneous transluminal coronary angioplasty (PTCA)

Improving long term interventional outcomes

No systemic pharmacological agent has resolved the problem of restenosis. There is currently much interest in mechanisms that alter cell proliferation thereby limiting NI.

Summary

Percutaneous interventions are now the mainstay of the treatment of symptomatic coronary narrowing, whether primarily due to atherosclerosis or secondary to previous procedures (restenosis). As demonstrated above, the current therapies to improve short and long term outcomes were designed on a background of scientific understanding of the disease processes. Further improvements in both the medical therapy and the application of this technology are dependent on further elucidation of the

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