An older man searches for relief from years of sporadic chest pressure
Mr. R, a 64-year-old Hispanic man, presented to our outpatient clinic complaining of pressure in his anterior chest. He reported that this central chest pressure has been occurring intermittently for the past 10 years on exertion. This most recent episode struck approximately one hour before his arrival at the clinic while he was sweeping snow from his sidewalk. He was not in pain at the time of examination and reported no other complaints (e.g., nausea, vomiting, or radiation of pain to his arms, jaw, back, or shoulders).
Past medical history included coronary artery bypass graft (CABG) 10 years before because of MI and chronic angina two to three times per week. Past and present comorbidities included successfully treated hypertension, chronic obstructive pulmonary disease (COPD) from a 35-pack-year history of tobacco use, and recent onset of erectile dysfunction. He reported no allergies to foods or medications. Mr. R's daily medication regimen included amlodipine (Norvasc) 10 mg, aspirin 50 mg, lisinopril 10 mg, clopidogrel (Plavix) 75 mg, simvastatin (Zocor), theophylline 400 mg, and one multivitamin as well as sildenafil (Viagra) 25 mg as needed. When asked what brought him to the clinic, Mr. R responded that he wanted to know what other medication could be prescribed to relieve the chest pressure.
Physical examination revealed an alert, articulate, afebrile, well-nourished adult in no acute distress. BP while seated was 136/84 mm Hg, and heart rate was regular at 66 beats per minute without murmurs or extra beats. Chest auscultation revealed scattered rhonchi in the bilateral mid- and lower-lung fields, but when asked to cough, Mr. R was unable to produce any sputum. No jugular venous distension or murmurs were detected in the neck. Palpation of the anterior chest revealed an apical impulse 10 cm from the midsternal line. The abdomen revealed no bruits or masses. There was no soft-tissue bruising or swelling of the extremities. The patient had full range of motion in his neck and peripheral joints.
Hematology, serum biochemistry, and cardiac enzymes revealed no deviations from normal. Theophylline level was therapeutic. Urinalysis showed no signs of renal dysfunction or UTI. A surface ECG revealed nonspecific T-wave inversion inferiorly, an old anterior MI, and QTc duration of 400 msec.
Following consultation with the cardiology service, the patient was taken to the diagnostic catherization lab for evaluation and assessment of his coronary grafts. The following findings were obtained:
- Left ventricular ejection fraction of 45% with moderate hypokinesis of the anterior wall
- Severe three-vessel coronary disease
- Patent left internal mammary artery (LIMA) graft to the left anterior descending coronary artery without distal disease
- Occluded saphenous vein graft (SVG) to the right coronary artery
- Myocardial perfusion imaging revealed diffuse disease with extensive subendocardial ischemia
A discussion was initiated at this point by the cardiology fellow to determine how Mr. R wanted to proceed with his care.
In consultation with the patient's cardiologist, the decision was made to prescribe ranolazine (Ranexa) extended-release tablets 500 mg b.i.d. A follow-up appointment with his cardiologist was scheduled for further treatment considerations. Mr. R was discharged from the clinic and instructed to alert his cardiologist immediately if he experienced nausea, headache, dizziness, or constipation while taking this new medication.
CLINICAL ANALYSIS AND DISCUSSION
Chronic stable angina remains a challenge, despite numerous advances in medical therapy and cardiovascular interventions. Historically, angina has been associated with a mismatch between oxygen supply and demand at the level of the coronary arteries perfusing the heart muscle. In this patient, a previous CABG procedure utilizing SVG and LIMA grafts was employed to correct this blood-flow pathology. However, Mr. R was not a good candidate for any additional endovascular procedures (e.g., coronary stent placement) because of the anatomic rearrangements from his CABG 10 years ago. In addition, his diagnostic evaluation in the cath lab confirmed the presence of subendocardial ischemic changes. Mr. R's medical therapy was also complicated by sildenafil, which obviated the use of sublingual or long-acting nitrates to alleviate his persistent chest pressure. And because of his COPD history, a beta blocker was contraindicated.
The American College of Cardiology/American Heart Association 2002 Guideline Update for the Management of Patients with Chronic Stable Angina concludes that “for most patients, the goal of treatment should be complete, or nearly complete, elimination of anginal chest pain and return to normal activities and functional capacity.”
Clinicians have been fairly successful in attaining only the first of these goals. Those who treat cardiovascular disease will frequently remark that their patients must “downsize” their lives in order to achieve symptomatic relief from persistent angina or angina-equivalent symptoms (e.g., dyspnea, fatigue, light-headedness, or weakness), despite treatment with beta blockers, calcium channel blockers, and nitrate. Enhanced external counterpulsation therapy (EECP) is one nonsurgical intervention that provides some relief for chronic angina and heart failure patients. The logistics of carrying out a successful treatment plan, however, sometimes creates additional burdens for the patient and his family. EECP involves transportation to a facility with the appropriate equipment (sometimes quite far from the patient's home) and a commitment to endure seven weeks of hour-long treatment sessions five days a week.
Ranexa, approved only last year, is indicated for chronic angina and used as a complement to calcium channel blockers, beta blockers, or nitrates. The effects of Ranexa are hemodynamically neutral to BP and heart rate, but the manufacturer (CV Therapeutics) recommends the twice-daily medication be prescribed under the direct supervision of a cardiologist.
Mr. R was reluctant to undertake a new EECP regimen and wanted to try Ranexa instead. After a month on the drug, he reported decreased incidence of chest pressure during his activities at home and was in the process of interviewing for a new full-time job.