Recurrent and resistant angina: is the metabolic approach an appropriate answer?

Area of Science:

• Cardiology
• Ischemic Heart Disease
• Interventional Cardiology

Background:

• Chronic stable angina is a primary manifestation of ischemic heart disease, affecting millions annually with significant morbidity.
• Myocardial revascularization is often pursued for symptom relief and mortality prevention in refractory angina.
• Current evidence questions the long-term benefits of revascularization for reducing myocardial infarction or mortality.

Purpose of the Study:

• To evaluate the efficacy of percutaneous transluminal coronary angioplasty (PTCA) in chronic coronary artery disease.
• To compare PTCA outcomes with medical therapy regarding symptomatic relief and hard clinical endpoints.
• To explore mechanisms contributing to persistent angina after revascularization and introduce novel therapeutic strategies.

Main Methods:

• Review of current evidence on PTCA versus medical therapy for chronic stable angina.
• Analysis of factors contributing to angina persistence post-revascularization.
• Discussion of emerging pharmacological approaches targeting cardiac energy metabolism.

Main Results:

• PTCA provides superior short-term symptomatic relief and improved exercise tolerance compared to medical therapy.
• PTCA does not significantly reduce the rates of subsequent myocardial infarction or overall mortality.
• Symptomatic benefits of PTCA diminish over time, with mechanisms like microvascular dysfunction implicated in persistent angina.

Conclusions:

• While PTCA improves angina symptoms, it does not alter the long-term prognosis regarding myocardial infarction or mortality.
• Incomplete revascularization, graft failure, disease progression, and microvascular dysfunction contribute to persistent angina.
• Metabolic agents offer a novel therapeutic avenue by targeting cardiac energy metabolism, distinct from traditional hemodynamic agents.