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In this trial involving 2492 patients, coronary revascularization guided by iFR, as compared with fractional flow reserve-guided revascularization, was within the prespecified margin for noninferiority with respect to major adverse cardiac events. For the past 20 years, physiological measurements obtained during invasive procedures have been used to guide coronary revascularization. Pioneering work supported the use of flow measurements to make safe decisions about revascularization, 1 , 2 but this approach was soon superseded by the use of fractional flow reserve (FFR), which measures pressure as a surrogate of flow to estimate the severity of stenosis. 3 – 5 FFR was successful largely because of its technical simplicity and because clinical trials showed that it was associated with improved clinical outcomes after percutaneous coronary intervention (PCI). 6 , 7 Consequently, FFR is now included in the appropriate-use criteria for . . .

In this multicenter trial, 3561 patients with stable chest pain at intermediate risk for obstructive coronary artery disease were randomly assigned to undergo CT or invasive coronary angiography. Over 3.5 years of follow-up, there was no significant between-group difference in the risk of major adverse cardiovascular events. Major procedure-related complications were less common with CT.

In the COURAGE trial, percutaneous coronary intervention (PCI), added to optimal medical therapy, did not reduce the subsequent rate of death or myocardial infarction among patients with chronic coronary disease. A quality-of-life analysis showed that measures of health status improved significantly with either strategy, but patients in the PCI group had greater initial improvements. In the COURAGE trial, percutaneous coronary intervention (PCI), added to optimal medical therapy, did not reduce the subsequent rate of death or myocardial infarction among patients with chronic coronary disease. A quality-of-life analysis showed that measures of health status improved significantly with either strategy, but patients in the PCI group had greater initial improvements. Clinical trials involving patients with chronic coronary artery disease, in contrast to those involving patients with acute coronary syndromes, have not shown that percutaneous coronary intervention (PCI) prevents major cardiovascular events. 1 – 5 The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial compared a strategy of PCI plus optimal medical therapy with optimal medical therapy alone and showed no significant difference in the rate of the primary end point (death or myocardial infarction) during a median follow-up period of 4.6 years. 6 Among patients with stable coronary artery disease, PCI is indicated for the relief of angina. 2 , 3 , 7 , . . .

IntroductionThe clinical effectiveness of a ‘rule-out’ acute coronary syndrome (ACS) strategy for emergency department patients with chest pain, incorporating a single undetectable high-sensitivity cardiac troponin (hs-cTn) taken at presentation, together with a non-ischaemic ECG, remains unknown.MethodsA randomised controlled trial, across eight hospitals in the UK, aimed to establish the clinical effectiveness of an undetectable hs-cTn and ECG (limit of detection and ECG discharge (LoDED)) discharge strategy. Eligible adult patients presented with chest pain; the treating clinician intended to perform investigations to rule out an ACS; the initial ECG was non-ischaemic; and peak symptoms occurred <6 hours previously. Participants were randomised 1:1 to either the LoDED strategy or the usual rule-out strategy. The primary outcome was discharge from the hospital within 4 hours of arrival, without a major adverse cardiac event (MACE) within 30 days.ResultsBetween June 2018 and March 2019, 632 patients were randomised; 3 were later withdrawn. Of 629 patients (age 53.8 (SD 16.1) years, 41% women), 7% had a MACE within 30 days. For the LoDED strategy, 141 of 309 (46%) patients were discharged within 4 hours, without MACE within 30 days, and for usual care, 114 of 311 (37%); pooled adjusted OR 1.58 (95% CI 0.84 to 2.98). No patient with an initial undetectable hs-cTn had a MACE within 30 days.ConclusionThe LoDED strategy facilitates safe early discharge in >40% of patients with chest pain. Clinical effectiveness is variable when compared with existing rule-out strategies and influenced by wider system factors.Trial registration number ISRCTN86184521.

In a randomized trial, patients with coronary artery disease underwent PCI guided by either the instantaneous wave-free ratio or fractional flow reserve. At 1 year, iFR-guided PCI was noninferior to FFR-guided PCI with respect to the rate of major adverse cardiac events. Coronary revascularization is warranted only if a patient has one or more coronary-artery stenoses that are hemodynamically important. Large randomized studies have shown that fractional flow reserve (FFR) is superior to angiographic assessment for the detection of hemodynamically important coronary-artery stenoses and that use of FFR to guide coronary revascularization improves clinical outcomes. 1 – 3 FFR is measured by advancing a coronary-pressure guidewire distal to a stenotic lesion and then administering adenosine to assess the pressure gradient across the lesion during hyperemia. Studies have shown that resting indexes (derived from the pressure measurement at rest, without the administration of adenosine) have . . .

In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for traditional first-choice drugs. Considering some drugs, but not others, to be first choice is, therefore, difficult. Moreover, double or triple therapy is often needed to control angina. Patients with angina can have several comorbidities, and symptoms can result from various underlying pathophysiologies. Some agents, in addition to having antianginal effects, have properties that could be useful depending on the comorbidities present and the mechanisms of angina, but the guidelines do not provide recommendations on the optimal combinations of drugs. In this Consensus Statement, we propose an individualized approach to angina treatment, which takes into consideration the patient, their comorbidities, and the underlying mechanism of disease.

Implantation of a device to narrow the coronary sinus and increase myocardial venous pressure was compared with a sham procedure in patients with refractory angina. The proportion of patients with improvement at 6 months was significantly greater with the device. A growing number of patients with severe and diffuse obstructive coronary artery disease who are not candidates for revascularization have debilitating angina despite medical therapy. 1 – 3 The worldwide prevalence of refractory angina is increasing, and new therapeutic options are needed. 4 An endoluminal, balloon-expandable, stainless steel, hourglass-shaped device designed for percutaneous implantation in the coronary sinus (Reducer, Neovasc) creates a focal narrowing that leads to increased pressure in the coronary sinus, which may relieve angina (Figure 1). A nonrandomized first-in-human study involving 15 patients with refractory angina who were treated with the device showed significant improvement with respect to angina class. . . .

Objectives We conducted a randomised, double blind, placebo controlled trial to assess the efficacy and safety of cilostazol, a selective inhibitor of phosphodiesterase 3, in patients with vasospastic angina (VSA). Background Cilostazol has been shown to induce vascular dilatation, but its efficacy in patients with VSA is unknown. Methods Between October 2011 and July 2012, 50 patients with confirmed VSA who had ≥1 angina episodes/week despite amlodipine therapy (5 mg/day) were randomly assigned to receive either cilostazol (up to 200 mg/day) or placebo for 4 weeks. All patients were given diaries to record the frequency and severity of chest pain (0–10 grading). The primary endpoint was the relative reduction of the weekly incidence of chest pain. Results Baseline characteristics were similar between the two groups. Among 49 evaluable patients (25 in the cilostazol group, 24 in the placebo group), the primary endpoint was significantly greater in the cilostazol group compared with the placebo group (−66.5±88.6% vs −17.6±140.1%, respectively, p=0.009). The secondary endpoints, including a change in the frequency of chest pain (−3.7±0.5 vs −1.9±0.6, respectively, p=0.029), a change in the chest pain severity scale (−2.8±0.4 vs −1.1±0.4, respectively, p=0.003), and the proportion of chest pain-free patients (76.0% vs 33.3%, respectively, p=0.003) also significantly favoured cilostazol. Headache was the most common adverse event in both groups (40.0% vs 20.8%, respectively, p=0.217). Conclusions Cilostazol is an effective therapy for patients with VSA uncontrolled by conventional amlodipine therapy, and has no serious side effects. Trial registration number NCT01444885.

BackgroundIn patients with suspected angina pectoris, CT coronary angiography (CTCA) clarifies the diagnosis, directs appropriate investigations and therapies, and reduces clinical events. The effect on patient symptoms is currently unknown.MethodsIn a prospective open-label parallel group multicentre randomised controlled trial, 4146 patients with suspected angina due to coronary heart disease were randomised 1:1 to receive standard care or standard care plus CTCA. Symptoms and quality of life were assessed over 6 months using the Seattle Angina Questionnaire and Short Form 12.ResultsBaseline scores indicated mild physical limitation (74±0.4), moderate angina stability (44±0.4), modest angina frequency (68±0.4), excellent treatment satisfaction (92±0.2) and moderate impairment of quality of life (55±0.3). Compared with standard care alone, CTCA was associated with less marked improvements in physical limitation (difference −1.74 (95% CIs, −3.34 to −0.14), p=0.0329), angina frequency (difference −1.55 (−2.85 to −0.25), p=0.0198) and quality of life (difference −3.48 (−4.95 to −2.01), p<0.0001) at 6 months. For patients undergoing CTCA, improvements in symptoms were greatest in those diagnosed with normal coronary arteries or who had their preventative therapy discontinued, and least in those with moderate non-obstructive disease or had a new prescription of preventative therapy (p<0.001 for all).ConclusionsWhile improving diagnosis, treatment and outcome, CTCA is associated with a small attenuation of the improvements in symptoms and quality of life due to the detection of moderate non-obstructive coronary artery disease.Trial registration number:NCT01149590.

In the ISCHEMIA trial, patients with stable ischemic heart disease were randomly assigned to invasive or conservative treatment. As reported separately, the invasive strategy did not reduce clinical events. Improvements in health status were slightly greater with the invasive strategy, reflecting minimal effects in asymptomatic patients and larger effects in patients with angina symptoms at baseline.