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

Management of Stable Angina  GTN  Aspirin (Clopidogrel)  Statin (Ezetimibe)  ACE Inhibitor  β-Blocker  Second-line drug –Calcium antagonist –Long-acting nitrate –K + agonist –I f channel blocker

Management of Stable Angina  What investigations can guide therapy?  Where does revascularisation fit in?  What other drugs are available?  Are there any other options?

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?

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

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?

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

Courage – Nuclear Sub-study  314 Patients  MPS scans: Baseline, 6/12, 18/12  2 groups –<10% ischaemia –>10% 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

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?

Mechanisms of Drug Action  Reduce Heart Rate –β-Blockers, Verapamil/Diltiazem, Ivabradine  Reduce Blood Pressure –β-Blockers, Calcium Antagonists  Reduce Contractility –β-Blockers, Verapamil/Diltiazem  Coronary Vasodilators –Diltiazem, Amlodepine, Nicorandil, Nitrates

Mechanism of action does not involve interference with haemodynamic variables Ranolazine

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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

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