The Late Sodium Current in the cardiac myocite: How viable as a new therapeutic target in angina?

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The Late Sodium Current in the cardiac myocite
How viable as a new therapeutic target in angina?
SPONSORED SATELLITE SESSION
Dr Stephen Holmberg Lead Consultant for Cardiac
Services Brighton Sussex University Hospitals
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Management of Stable Angina

• GTN
• Aspirin (Clopidogrel)
• Statin (Ezetimibe)
• ACE Inhibitor
• ß-Blocker
• Second-line drug
• Calcium antagonist
• Long-acting nitrate
• K agonist
• If channel blocker

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Management of Stable Angina

• What investigations can guide therapy?
• Where does revascularisation fit in?
• What other drugs are available?
• Are there any other options?

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Management of Stable Angina

• What investigations can guide therapy?
• Treadmill MIBI Stress Echo CMR
• EBT CT Angio Invasive Angio
• Where does revascularisation fit in?
• What other drugs are available?
• Are there any other options?

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Prognosis in Stable Angina

• Generally benign
• Very difficult to demonstrate prognostic benefit
  of anti-anginal medication
• Exercise Testing
• Short treadmill tolerance (for whatever reason)
  is poor prognostic feature
• Scale of Ischaemia
• MIBI scan accepted by DVLA/CAA
• Angiographic Findings
• Triple vessel disease with LV impairment
• Significant Left Main Stem disease
• But NOT.... Symptoms
• Silent ischaemia has same prognosis as painful
  angina

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Management of Stable Angina

• What investigations can guide therapy?
• Where does revascularisation fit in?
• What does COURAGE tell us?
• What other drugs are available?
• Are there any other options?

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Courage

• All patients had angiographic assessment
• Extremely small percentage of eligible patients
  randomised
• High level of cross-over to PCI for symptomatic
  patients
• No assessment of ischaemia in main trial

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Courage Nuclear Sub-study

• 314 Patients
• MPS scans Baseline, 6/12, 18/12
• 2 groups
• lt10 ischaemia
• gt10 ishaemia
• Endpoint
• Reduction in ischaemia
• PCI -2.7. Medical -0.5.
• Risk of death/MI significantly reduced for
  patients with significant reduction in ischaemia
  especially in those with high baseline ischaemic
  burden

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Management of Stable Angina

• What investigations can guide therapy?
• Where does revascularisation fit in?
• What other drugs are available?
• Ranolazine Perhexiline - Trimetazidine
• Are there any other options?

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Mechanisms of Drug Action

• Reduce Heart Rate
• ß-Blockers, Verapamil/Diltiazem, Ivabradine
• Reduce Blood Pressure
• ß-Blockers, Calcium Antagonists
• Reduce Contractility
• ß-Blockers, Verapamil/Diltiazem
• Coronary Vasodilators
• Diltiazem, Amlodepine, Nicorandil, Nitrates

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Ranolazine

• Mechanism of action does not involve interference
  with haemodynamic variables

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Management of Stable Angina

• What investigations can guide therapy?
• Where does revascularisation fit in?
• What other drugs are available?
• Are there any other options?
• Exercise training Spinal cord stimulation

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Conclusions

• Follow the ESC Guidelines
• Assessment of ischaemia is important
• Revascularisation where feasible/sensible
• New drug therapies such as Ranolazine offer hope
  to refractory patients