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Clinical cases where an indication for Ranolazine may exist/ Part 2

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I thought perhaps we could consider cases enough okay cross comes with some some cases and i thought maybe opinion about whether already appropriate in these little cases i know we talked about you know that one ought to monitor and make sure it is safe for certain groups that would want to make sure that the renal function is is appropriate yes they not there’s

No impairment and likewise liver function tests yes any other things that one needs to consider before considering starting a patient on it yeah i else i think they’re the main two groups as well as the lt i think it’s important to say that with kidney disease when you have end-stage kidney disease and your estimated glomerular filtration rate is less than 30

Is actually a contraindication for over known as in and again these are a very small group of patients who will be within the hospital setting and are often quite difficult to treat but no there’s no other major groups great okay i just had this you know i thought of said you know getting your opinion you know this this man who’s had a cabbage already has been

Considered again for revascularization but thought to be high risk yes he’s already on a lot of pain he’s already on bisoprolol and he’s also on it isosorbide mononitrate yes he’s still getting symptoms and journal symptoms yes cardiovascularly he is stable his blood pressure is not is not very high you act it’s 110 120 systolic diastolic run about 6070 pulse around

About 60 or below not higher than that would you consider in this particular is his renal functions fine over 60 egfr liver functions table how old is he he’s 73 yes but he’s asian okay so he’s a gentleman that’s had a bypass operation who’s got recurrent angina i think you’ve done the most important thing with these patients i think they should come back to the

Hospital setting to further revascularization issues explore which has clearly happened but saying that i mean we need to remember that in this group of patients whatever we do is largely going to be for symptomatic rather than prognostic benefit so i think it’s perfectly reasonable to explore medical therapy now he doesn’t appear to have any real contraindications

To were noticing i think before i went into giving that i would want to explore the titration of his existing drugs the first-line drugs to make sure that they are at optimal value as tolerated by the patient and also whether he’s you’re on a beta-blocker he’s already on a beat bisoprolol and the resting heart rate is resting heart rates of that roundabout between

50 and 60 so you’ve titrated the dose to get the resting heart rate down to the optimal value so there’s no point pushing on with getting the harm right down further so i think in this group of patients renan tree noticing remains a good drug there’s nothing that confirmed the case the patient well he’s you know he’s been advised but he’s been altered told the

Risks are high so he’s wondering what are his options he is the one open but i think if the risks of revascularization are high we should absolutely explore medical therapy and i would start him on ranolazine and a starting dose at his age of 500 milligrams twice a day his liver function his real functions normal i would advise him of the small risk of having

Gastrointestinal disturbances over the first two weeks i would reassess him in clinic purely for symptom to see how his symptoms have been controlled after four weeks and then you can go up further to 750 milligrams twice a day after that i think of at that point he remains very symptomatic it’s worthwhile referring him back to revisit the risk-benefit ratio of

Revascularization yeah as i said all ready you know he’s already under the his been seen again growth for revascularization accreditor because he’s not keen on accepting the risk that’s absolutely fine you know so i just thought perhaps he’s already on maximum dose tucked in great resume is starting and sitting with he had his first mi quite young yes and again

I think from a practical perspective we are simply titrating the dose according to symptoms there’s nothing else we need to consider because there’s no renal function monitoring card heart rate is purely going to be with symptoms so it will be easy patient to manage in terms of from your side okay okay another patient i thought i’d just go with you have already

Started ranolazine but i just wanted to see you know that’s what you would consider as well this is a another asian lady 75 year old known to suffer with cardiac syndrome x yes has that has done so for very many years again on on the quran dale atorvastatin gtn has been required she’s not been able to tolerate beta blockers even at a low dose yes and we struggled

And i’m just thinking of other you know calcium channel blockers she’s not been able to tolerate either there’s edema of lower legs address head side effects headaches so you know she who i was advised to consider but i was a bit because she’s only on reading the quran do and nothing else in terms of antianginal are there any other options yes i think the cardiac

Syndrome xo so these are patients who have angina often if you do what’s called a functional test you will see objective evidence of myocardial ischaemia but they have unobstructed coronary arteries and i think for many years some cardiologists actually found this a very difficult concept but the reality is when we do a coronary angiogram we only see ten percent

Of the karma tree we do not see the arterioles capillaries and so micro vascular angina is much more common than we think particularly in hypertensive patients and diabetic patients when strictly speaking they do not have seen dramatic sis due to their underlying blood pressure or diabetes now this group of patients should be treated the same way as those with

Obstructive disease in terms of their angina management and you’ve already explored all of the the more common drugs the first-line drugs and as ever there’s been a combination of some degree of success and some and some drugs which were not tolerated so i think you’ve already explored the first-line drugs and i think nick randall is the only one that this

Patient is tolerating so you need to go into the second line drugs you have options one is further heart rate lowering with i by brené or again you have the issue of a hemodynamically neutral drug such as ranolazine my own personal experience with syndrome x is that this is as effective in this microvascular angina groupers in the microvascular mangina group so

So so again i think it would be a useful drug again i haven’t demonstrated from the history anything that would make me worry about giving this drug great i mean i’ve seen her since and she does feel a bit better on university gtn users definitely decrease yes she feels quite happy with it and of course that would fit with our data in patients with obstructive

Disease so i think with with these micro vascular angina patients i think rena rena rosine should be considered as a second-line agent when the primary drugs have not worked or and here are moderated and this issue about micro vascular yes ischemia and you’re there you know ventricular myocardial tension is it better yet we’ve me in primary care i was just speaking

To a colleague yesterday here many of us are finding it difficult to sort of understand fully and come to terms with as it were because you know traditional teaching is your coronary arteries are clogged up with aromas and you know if you don’t see it you know you don’t need to treat or you find but it’s actually a bigger picture than that isn’t it it’s a much

Bigger picture i think we should always remember that angina remains a clinical diagnosis is based on history and only the history and i think of a patient describes angina they have angina now i think the purpose of testing is to look for major obstructive coral disease and if you don’t have that make sure you don’t have major valve disease or a cardiomyopathy

But if all of those tests are not showing these things then you are left with microvascular angina and this can be very this can be demonstrated with either what’s called a myocardial perfusion scan or a perfusion mri scan or a stress echocardiogram which i do a lot of so and what we know is that if you have a ischaemic burden demonstrated in this group you are

As symptomatic as if you have macro vascular disease so they should be treated in the same way so i think my message for primary care is that the history is the most important thing if you have angina and just have angina and if you don’t if you have coronary arteries that are unobstructed at angiography you have microvascular angina until proven otherwise so the

Thank you very much roger i think you’ve been very informative and helpful and tidying up some of my queries um one last thing yes we refer patients to folk to rule out of angina or some firm and to revascularization enough they they have their vascularization procedures done and they come back they still come back twenty-five to thirty percent is in my practice

You know we still left with them presenting with angina and they’re already on medicaid what should we be should we be referring them back to you it’s a very good point and i think again it’s something that’s emerged as we’ve collected more data over the years we often talk about medical management and revascularization as an either/or i think the reality is if

You take patients that have revascularization either with coronary angioplasty and stenting or with bypass surgery over a five-year period at least twenty-five percent of potions will either continue to have symptoms or will have recurrent symptoms so the reality is in a large number of people we have to consider both as an option and i would emphasize again in

Terms of prognosis for stable angina the most important things to focus in primary secondary and tertiary care are risk factor control as you’ve already pointed end and for me ace inhibitors so i think yes you’re right i think in this group that i’ll be vascularized my own view would be i would be symptom driven as to whether you refer back so i would start them

On a first lion antianginal agent i think if they’re continuing to get symptoms i would then go into a second line agent such as we know anything but i think it would be useful to refer them back for an valuation of their symptoms ischaemic burden and then we explore other options but i don’t think there’s there’s a rush to bring these patients back particularly

If they’re angina is not very frequent because revascularization as a second time in patients is very rarely associated with a prognostic improvement right okay redo that thank you thank you very much

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Clinical cases where an indication for Ranolazine may exist/ Part 2 By Cardio Debate