The International Journal of Biochemistry & Cell Biology
Medicine in focusAngina pectoris: interventional therapies and treatment of restenosis
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
References (25)
Percutaneous coronary intervention
Medicine
(2002)Cardiac intervention procedures in the United Kingdom1997: Developments in data collection. Council of the British Cardiovascular Intervention Society (http://www.bcis.org.uk)
Heart
(1999)- et al.
Inhibition of intimal thickening after balloon angioplasty in porcine coronary arteries by targeting regulators of the cell cycle
Circulation
(1999) - et al.
Death following coronary angioplasty
Heart
(2002) - et al.
Long term follow up after coronary angioplasty. The early Zurich experience
The New England Journal of Medicine
(1987) Vascular remodelling. Honey, I think I shrunk the artery
Circulation
(1994)- et al.
First clinical experience with a paclitaxel derivate-eluting polymer stent system implantation for in-stent restenosis
Circulation
(2002) - et al.
Photodynamic therapy: Shedding light on restenosis
Heart
(2001) - et al.
Bench to bedside: The development of rapamycin and its application to stent restenosis
Circulation
(2001) - et al.
The RAVEL Study Group. A randomised comparison of a sirolimus-eluting stent with a standard stent for coronary revascularisation
The New England Journal of Medicine
(2002)
The pathogenesis of atherosclerosis: A prospective for the 1990s
Nature
Cited by (6)
Safety and efficacy issues in designing drug-device combination products: The case of drug eluting stents
2009, Drug-Device Combination Products: Delivery Technologies and ApplicationsMembranes in drug delivery
2015, Handbook of Membrane Separations: Chemical, Pharmaceutical, Food, and Biotechnological Applications, Second EditionTherapeutic potential of nucleic acid-based drugs in coronary hyper-proliferative vascular diseases
2013, Current Medicinal ChemistryInterfacial biology of in-stent restenosis
2005, Expert Review of Medical DevicesAnalysis of prosthetic cardiac devices: A guide for the practising pathologist
2005, Journal of Clinical PathologyAlkoxybenzylcyanoguanidine analogs as a novel class of inhibitors for restenosis
2004, Bulletin of the Korean Chemical Society