CCS 2

Summary

The presentation focuses on optimizing therapy for chronic coronary syndromes, highlighting the use of Ranolazine as a viable treatment option. The speaker discusses the prevalence and prognosis of angina, emphasizing Ranolazine's role as an add-on or first-line therapy for patients not well-controlled by beta blockers or calcium channel blockers. Clinical trials and guidelines support its efficacy in reducing angina frequency, improving exercise tolerance, and lowering healthcare costs, particularly in patients with diabetes. The talk underscores individualized treatment and the benefits of Ranolazine in enhancing patient outcomes without significant hemodynamic effects.

Takeaways

• 🚑 Chronic coronary syndrome (CCS) patients with angina have a poorer prognosis and greater risk of cardiovascular events.
• 📊 Angina frequency is directly related to the risk of hospitalization after an acute coronary syndrome, impacting healthcare costs.
• 💊 Renolazine is presented as a viable add-on therapy for CCS patients inadequately controlled with first-line agents like beta blockers and calcium channel blockers.
• 📚 Guidelines suggest renolazine for CCS patients with persistent angina despite treatment with first-line therapies, emphasizing the need for individualized treatment plans.
• 🌡 Renolazine's mechanism of action involves improving diastolic tone, coronary blood flow, and potentially having an anti-arrhythmic effect without affecting heart rate or blood pressure.
• 💡 The CARISA trial showed renolazine significantly reduced angina frequency and nitroglycerin consumption, with a more pronounced effect in non-diabetic patients.
• 🤔 Renolazine is considered for patients with comorbidities such as diabetes, heart failure, or those who cannot tolerate first-line agents, offering a tailored approach to treatment.
• 📉 Renolazine has been associated with a reduction in HbA1c levels, suggesting a potential benefit for diabetic patients with CCS.
• 💼 The use of renolazine is supported by randomized control trials and meta-analyses, demonstrating its effectiveness and leading to guideline recommendations.
• 💡 The MERLIN-TIMI 36 trial and subsequent analyses highlight the drug's benefits in reducing angina and HbA1c levels, particularly in diabetic patients.
• 🌟 Optimal management of CCS should focus on improving prognosis and quality of life, with renolazine offering a non-inferior approach to revascularization in reducing cardiovascular death.

Q & A

What is the primary focus of the presentation?

The presentation focuses on optimizing medical therapy for chronic coronary syndromes and discusses why renolazine is a viable option for treating patients with this condition.

Why is angina considered both a symptom and a prognostic marker?

Angina is considered both a symptom and a prognostic marker because it indicates not only the presence of cardiovascular issues but also an increased risk for future cardiovascular events such as death, myocardial infarction, and hospitalization.

What are some key factors that increase the risk of cardiovascular death in patients with chronic coronary syndrome?

Key factors that increase the risk include diabetes, history of heart failure, pulmonary disease, peripheral artery disease, and atrial fibrillation.

Why is renolazine considered a useful add-on therapy for angina?

Renolazine is considered useful as an add-on therapy because it can help reduce the frequency of angina and improve exercise tolerance in patients whose symptoms are not adequately controlled by first-line agents like beta blockers and calcium channel blockers.

What are the recommended starting and maximum doses of renolazine in the Philippines?

The recommended starting dose of renolazine is 375 mg twice a day, which can be titrated to 500 mg twice a day after 2 to 4 weeks, with a maximum dose of 750 mg twice a day.

How does renolazine help in managing angina without affecting hemodynamic parameters?

Renolazine helps manage angina by improving diastolic tone and coronary blood flow without affecting heart rate or blood pressure. It acts by inhibiting late sodium channels, reducing sodium and calcium overload in the cells, and improving myocyte metabolic performance.

What evidence supports the use of renolazine as an effective treatment for angina?

Evidence from various trials, including the CARISA and MERLIN-TIMI 36 trials, supports renolazine's effectiveness. These trials showed significant reductions in angina frequency and nitroglycerin consumption among patients taking renolazine compared to placebo.

How does renolazine benefit patients with diabetes and angina?

Renolazine benefits diabetic patients by reducing both angina frequency and HbA1c levels, thus improving blood sugar control and angina symptoms simultaneously.

What is the role of individualized therapy in managing chronic coronary syndromes?

Individualized therapy involves tailoring treatment to each patient's characteristics, comorbidities, and preferences to maximize symptom relief and prevent cardiac events. This approach ensures optimal management of chronic coronary syndromes.

Why is optimal medical therapy emphasized over revascularization for patients with chronic coronary syndrome?

Optimal medical therapy is emphasized because it is non-inferior to revascularization in decreasing cardiovascular death and should be the primary approach to improve prognosis and quality of life for patients with stable chronic coronary syndrome.

Outlines

00:00

📊 Optimizing Medical Therapy for Chronic Coronary Syndromes

This paragraph provides an overview of the importance of choosing renolyzine as a treatment option for chronic coronary syndrome. It emphasizes the significance of angina as both a symptom and a prognostic marker, citing data from the Clarify registry and the Merlin trial. It explains that angina is linked to poorer prognosis and increased hospitalization costs. The paragraph concludes by introducing renolyzine as an effective add-on therapy to first-line agents like beta blockers and calcium channel blockers, highlighting its benefits and recommended dosages.

05:02

📈 Evidence and Guidelines for Treating Chronic Coronary Syndrome

This paragraph delves into the guidelines for treating patients with chronic coronary syndrome, emphasizing the need for optimal medical treatment before considering revascularization. It discusses the role of beta blockers and calcium channel blockers as first-line agents and the importance of individualizing patient therapy. The paragraph also highlights the benefits of renolyzine as an add-on therapy, particularly for patients with angina who are inadequately controlled with first-line treatments. It stresses the need to consider patient characteristics and comorbidities when selecting treatment options.

10:04

🧪 Clinical Trials Supporting Renolyzine

This paragraph reviews the clinical trials and evidence supporting the use of renolyzine in patients with angina and chronic coronary syndrome. It mentions the Carissa trial, which showed a significant reduction in angina frequency among patients receiving renolyzine compared to placebo. The paragraph also discusses the benefits of renolyzine in combination with other anti-anginal therapies, noting its positive effects on exercise capacity and angina symptoms. The importance of considering heart rate and blood pressure when prescribing anti-anginal agents is also highlighted.

15:06

💊 Renolyzine for Diabetic Patients with Angina

This paragraph focuses on the use of renolyzine in diabetic patients with angina, highlighting its potential benefits beyond angina relief. It discusses the Teresa trial, which showed a significant reduction in HbA1c levels among diabetic patients receiving renolyzine. The paragraph also explains the possible mechanisms behind renolyzine's glycemic effects, including its impact on pancreatic alpha cells and endothelial function. The importance of considering comorbidities, such as diabetes and peripheral artery disease, when selecting anti-anginal agents is emphasized.

20:07

💼 Cost-Effectiveness and Clinical Outcomes of Renolyzine

This paragraph summarizes the cost-effectiveness and clinical outcomes associated with renolyzine use in patients with stable coronary artery disease. It notes the significant reduction in hospitalization rates and overall healthcare costs for patients taking renolyzine compared to those on beta blockers and calcium channel blockers alone. The paragraph concludes by emphasizing the role of optimal medical therapy in improving prognosis and quality of life for patients with chronic coronary syndrome, highlighting renolyzine's advantages in angina relief and HbA1c reduction.

Keywords

💡Chronic Coronary Syndrome

Chronic Coronary Syndrome (CCS) refers to a group of conditions related to decreased blood flow to the heart muscle due to plaque buildup in the coronary arteries. It is a significant focus of the video as it discusses optimizing therapy for patients suffering from CCS. The presentation highlights the prevalence, risks, and treatment options, such as the use of renolazine, for managing this condition.

💡Renolazine

Renolazine is a medication used to treat chronic angina, a symptom of Chronic Coronary Syndrome. The video emphasizes its benefits as an add-on therapy to first-line agents like beta blockers and calcium channel blockers. Renolazine improves diastolic function, reduces angina frequency, and has a neutral effect on heart rate and blood pressure, making it a valuable option for individualized patient therapy.

💡Angina

Angina is chest pain or discomfort caused by reduced blood flow to the heart muscle, often a symptom of Chronic Coronary Syndrome. The video discusses angina as both a symptom and a prognostic marker, indicating a higher risk of cardiovascular events. Managing angina effectively with medications like renolazine can improve patient outcomes and reduce hospitalizations.

💡Prognostic Marker

A prognostic marker is a clinical or biological characteristic that provides information on the likely course of a disease. In the context of the video, angina serves as a prognostic marker for increased risk of cardiovascular events in patients with Chronic Coronary Syndrome. Recognizing and addressing these markers is crucial for improving patient prognosis and treatment outcomes.

💡First-line Agents

First-line agents are the initial medications recommended for treating a condition based on clinical guidelines. For Chronic Coronary Syndrome, these include beta blockers and calcium channel blockers. The video explains that while these drugs are effective, they may not be sufficient for all patients, necessitating the addition of second-line agents like renolazine for better management of angina.

💡Beta Blockers

Beta blockers are a class of drugs that reduce heart rate, the heart's workload, and its output of blood, which lowers blood pressure. They are commonly used as first-line agents for treating Chronic Coronary Syndrome and angina. The video mentions that beta blockers, despite their widespread use, may not always be the best option for every patient, highlighting the need for alternative therapies like renolazine.

💡Calcium Channel Blockers

Calcium channel blockers are medications that prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure. They are used as first-line treatment for Chronic Coronary Syndrome. The video discusses their role in managing angina and how they can be combined with other treatments like renolazine for patients who do not respond adequately to first-line therapy alone.

💡Diabetes

Diabetes is a chronic condition characterized by high blood sugar levels. It is a significant comorbidity in patients with Chronic Coronary Syndrome, affecting treatment outcomes. The video highlights that patients with diabetes may have a different response to angina treatment and that renolazine not only helps in managing angina but also has beneficial effects on blood sugar levels, making it a suitable option for these patients.

💡Guideline Recommendations

Guideline recommendations are evidence-based suggestions provided by medical authorities to guide the treatment of specific conditions. The video references guidelines from organizations like the American College of Cardiology and the European Society of Cardiology, which recommend renolazine as an add-on or second-line therapy for managing angina in Chronic Coronary Syndrome. These guidelines help clinicians make informed treatment decisions.

💡Hemodynamic Effects

Hemodynamic effects refer to the impact a drug has on blood flow and blood pressure. In the video, renolazine is highlighted for its lack of significant hemodynamic effects, meaning it does not notably alter heart rate or blood pressure. This makes it a safer option for patients who may not tolerate other anti-anginal agents that do have significant hemodynamic effects.

Highlights

Renolyzine is presented as a viable option for treating chronic coronary syndromes.

Angina is identified as both a symptom and a prognostic marker for increased cardiovascular risk.

The Clarify registry data shows that patients with angina have poorer prognosis and greater events.

The MERLIN-TIMI trial links angina frequency to the risk of hospitalization after acute coronary syndrome.

Certain comorbidities like diabetes, heart failure, and pulmonary disease increase cardiovascular risk in chronic coronary syndrome patients.

Renolyzine can be an add-on therapy to first-line agents for better angina control.

Guidelines recommend Renolyzine as a second-line therapy for patients with uncontrolled angina.

The CARISA trial demonstrates Renolyzine's effectiveness in reducing angina frequency in diabetic and non-diabetic patients.

Meta-analysis supports Renolyzine's benefit in reducing weekly angina frequency and nitroglycerin consumption.

Renolyzine's mechanism involves improving diastolic tone, coronary blood flow, and potentially having an anti-arrhythmic effect.

The importance of individualizing therapy based on patient characteristics and preferences is emphasized.

Renolyzine is recommended for patients with contraindications or intolerance to first-line agents.

Diabetic patients may experience angina despite normal coronaries and may benefit from Renolyzine treatment.

Renolyzine has been shown to improve glycemic control, reducing HbA1c levels in diabetic patients.

The Severus meta-analysis supports Renolyzine's benefits in reducing angina and HbA1c levels in patients with diabetes.

Renolyzine is cost-effective, reducing revascularization rates and overall cardiovascular health care costs.

Optimal medical therapy with Renolyzine is non-inferior to revascularization in decreasing cardiovascular death.

Transcripts

optimizing medical

therapy for chronic coronary syndromes

so the following slides will at least

give you a background on the science

on why we should choose renolyzine as an option

or a viable option for the treatment of our patients

with chronic coronary syndrome

so this is just a disclaimer

and a declaration of my conflict interest

so this will be just a short outline of my thought

so I will be discussing to you first

the prevalence of Angelina

ask a symptom and ask a prognostic marker

so in this clarify registry

you can see here that patients were actually look into

know when they have Angena

or those patients with evidence of ischemia

based on non invasive tests

like your stress test and your to the echo

and they found out that those patients who

despite having

or not having ischemic evidence in non invasive tests

may actually present with angina

and those patients with angina have poorer prognosis

or have actually greater events

and those patients who have no symptoms of angina

basically angina is not just a symptom

but also a prognostic marker

that will actually tell us

of a patient with increased risk

for cardiovascular event

whether that's death or non fatal

and fatal myocardial infection

now this result from the Merlin

teeny trial showed that angiena frequency

is also directly related to the risk of pre

hospitalization after an acute coronary syndrome

so patients

who actually have been treated in the hospital

for acute coronary events

may later on experience angina

and those patients with recurrent angina

are also at risk current hospitalization

and that translates to increase cost in the hospital or

um people increase in their health care cost

so patients were actually in the solid bar

or solid line rather who are experiencing daily angina

have actually increased hospitalization rate

and that translates to increase hospitalization cost

now there are also certain capabilities

that may increase the risk of cardiovascular death

among patients with chronic coronary syndrome

and again

that is coming from the data of the clarified registry

so you look at this patients with diabetes

those patients with history of heart failure

or those with pulmonary disease

peripheral artery disease and HL

fibrillation are actually at increased

risk of cardiovascular outcomes

and those without those comradeities

now

why renollazine is an option in the tailored approach

in treating angiena

because renexa can be an add on therapy

in the first line agents that uh

the guidelines has been telling us

if that is actually your data blockers

and Calcium channel blockers

but there has been actually no evidence that um

beta blockers are actually greater in terms of outcome

or better in terms of outcome

compared with the second line options

so but still because these are first line agents

probably because these are uh

this has been available for a long time and uh

trials have been shown that in the past

now this drugs are actually uh

effective in treating angiena

so there they become the first line agent

besides they are also being used as drugs

not for treatment of hypertension and heart failure

so far it's like hitting two birds in one stone

that's why we may consider them as the first line agent

but when you consider an ex up for an add on therapy

in patients with angina

who are in adequately controlled or in polyureate

the first like anti anginal therapies

then we have to start the station on 370

375mg twice a day

and by trade them to 500 mg vid after 2 to 4 weeks

until you reach the maximum dose

in the Philippines of 750 mg

twice a day

now the guidelines as Doctor um

mighty Ramirez has emphasized earlier

has um

relegated rhinolazine or other agents as an add on

or a second line therapy

to reduce the frequency of angina

and improve exercise tolerance

among those stations

whose angina is not controlled with beta blockers

or Calcium channel blockers

or those stations is

can also be given as the first line therapy

if

among our patients who already had contraindications

or with symptoms

and cannot tolerate the first line agents

likewise the American College of cardiology

also recommends rettolazine

in patients who remain symptomatic

despite treatment with data blockers

Calcium channel blockers or long acting nitrates

so they are already guideline recommendations

now because these are recommended by guidelines

let's now take a look at the

evidence

as why guidelines have relegated them as class 1 or 2A

for the treatment of patients with Angelina

so how do we now treat the patients optimally

so the nice guidelines

still recommends that we have to

maximize medical treatment

for patients with chronic coronary syndrome

before revvascularization

and when we say optimal treatment

we consider the patients

symptoms has been satisfactorily controlled

and that there has been prevention of cardiac events

by giving your drugs that prevent secondary events

not like your anti platelets and your anti

or your status no

and we also consider the patients adherents

and minimal adverse events as possible

drug therapies according to uh

the guidelines also suggest that we need to adapt uh

we we should give them to adapt to each patients

characteristics and preferences

so we highlight

that we need to individualize patient therapy

not and occupise medical treatment

by making sure that patient symptoms are relieved

and that we prevent cardiac outcomes

so as I have mentioned earlier

first choice is not necessarily backed up by robbers

evidence as a matter of fact

beta blockers or culture channel blockers

been recommended as First Choice

has no randomized control trials today

when compared with other agents

asks better strategy to an alternative strategy

using your metabolic modulators

when you prescribe them in patients with angiena

so several second

add on antisemic drugs such as your nitrates

your metabolic modulators like a renolyzine

trimetazzidine and to a lesser extent

evaporative for your patients with tachycardia

or those who remains to have heart rate B

at 70 beats per minute may prove beneficial

in combination with a beta blocker

or galcium channel doctor ask your first line therapy

again we look at patients characteristics

so the manalis um diagram has given us

at least

to look at the heart rate and the blood pressure

as possible hemodynamic

paramic is that we need to consider

when we adjust or add on other agents

and we know that retholazine is hemodynamic

um uh

has no hypodynamic effect

nor in terms of heart rate and blood pressure

and its anti antigenal effect

uh acts through improvement in diastolic tone

coronary blood flow

and a potential anti arrhythmic effect

now rethonazine

acts by inhibiting your late sojum channels

by decreasing your sojum overload

and if it acts on that sodium Calcium channels

not it also prevents

or decrease Calcium overload in the cells

or inner vasculature

improving diastolic stiffness of the heart

and improving myocytes metabolic performance

so basically

it improves the diastolic stiffness of the heart

not

and that improves blood flow to your coronary arteries

again

there are certain measures that we need to consider

in patients with angina remember patients with C a

B may present with angina

and some of them may actually have hypertension

and because of procomitant

other diseases may have lower heart rate

or maybe not tolerate to other agents

okay so some of the side effects related to

hypodynamic agents may be

of course edema or headaches

now nitrates data blockers

and Calcium channel blockers

are all hemodynamic agents

affecting your heart rate

systemic blood pressure peripheral vascular assistance

but all of this

anti anginal drug definitely gives symptom relief

however not all have outcome benefits

but has certain recommendations by guidelines

as relegate at

which relegates them as Class 1A

when they are given as first line

or a second line treatment

now we emphasize here that agents such as uranotasim

and trinitazithe are he

would they not depending

neutral agents that gives symptom relief

no and has been recommended by guidelines

so again we emphasize individualizing therapy

and combining treatment for patient with Agina

to improve patients outcomes

and when we say individualized

we consider certain capabilities

for example

of course the presence of diabetes which can be common

a reason why patients may remain to be symptomatic

even despite re vascularization

now we also consider patients hemodynamics

and patient driven outcome

like functional capacity

side effect and cost of treatment

now we look at evidence when a redology has been given

that class 1

recommendation by the European Society of cardiology

and class 2 a by the American Heart Association

so there are a lot of

randomized control trials that back up

the benefit of rethology in patients

with Angelina and Carissa

trial which was done among diabetic

and non diabetic patients

compare the frequency of Argina at week 12

regardless of the diabetes status

among those patients who receive renolazine

and they found out that those patients

who were receiving 750 mg

twice a day of renolazine compared with placebo

actually have significant reduction by at least 42%

which is more pronounced in patients with no diabetes

than those patients with diabetes

and it is meta analysis

of patients with chronic coronary syndrome

involving 9,000 patients with symptoms of angina

who receive renalyzine

as an add on to conventional therapy

and conventional treatment would include beta blockers

Calcium channel blockers and nitrate

have significant reduction in the weekly

engine of frequency

and weekly nitroglycerin consumption

back to just taking those first line agents

without so much effect on their hymodynamic status

they also look at the systematic review

and meta analysis on the different parameters

which is laboratory parameters

not as seen in the exercise time duration

and the time to SD segment

depression in time to and gene

as you can see here

when retholazine was added to beta blockers

and Calcium channel blockers

there were actually better outcomes

compared to those patients who were receiving um uh

beta blockers and Calcium channel blockers

in addition to your long acting nitrates

and this diagnostic test

not also translates to clinical outcome

in such the patients who were on Rethologis

have actually fewer angile frequency and nitrate use

compared to just receiving alchem channel blockers

or beta blockers alone

now when you can see here

the individual effect of each agents

like your evaporine beta blockers

schaltium antagoniste and renolyzine

the addition of renolyzine at 750 mg

twice a day as the maximum dose of your renolyzine

when are dead on top of your baseline uh

therapy for angina

actually resulted in 23% relative risk production

in anti angina uh

in exercise capacity compared to those patients who is

who were receiving the uh

baseline drugs

such as your beta blockers or your Calcium antagonist

I'm sure you remember this light

which Doctor Ramirez has shown earlier

that there

are parameters that we need to take into account

when giving your anti andgenal agents

and that includes your heart rate

and your blood pressure why your heart rate

if the blood pressure remains to be tachycardic

beyond 60 feets per minute

then by no means you can add your evaporating

to lower your heart rate and improve the

the cardiac um outcomes

not of this station not the cardiac demand and supply

and for patients whose blood pressure uh

is beyond hundred twenty systemic millimeters mercury

you can opt to give them your hypodynamic agents

because you know that these drugs

can also affect your blood pressure

later on now

if the patient may remain to be symptomatic

or the patient cannot tolerate the drug

uh like your meta blockers and your nitrates

then you can already give your renolyzine

not if your patient's blood pressure is at

still elevated

or if your heart rate is still increased

then you can add on your evaporative

so

regardless whether your blood pressure is high or low

you can safely add your analyzine

or your trimetacidine ask your metabolic modulators

so

there are important issues when we talk about ischemia

especially among diabetic patients

so there are a lot of patients with diabetes

who are complaining of angina

even if their coronaries are normal

diabetic patients may present with a typical angina

shortness of breath instead of chest pain

they may also worsen with conventional data blockers

and data blockers may even block hypoglycemic symptoms

about patients taking diabetic medications

peripheral artery disease

which is fairly common in patients

be that with diabetes may not actually tolerate some

or the old beta blockers

and they even need non vasodilating beta block

vasodilating beta blockers

and the non vasodilating are types of data blockers

may even be contraindicated

hence in this group of patients

renollazine can still be an option

even as a first flight agent

also with an improved reduction in H d

A1C giving us a potential benefit

even in patients with microvascular dysfunction

and no negative endometabolic effects

so again highlighting this diagram by Doctor Vera

and showing to us

individualizing treatment by looking at patients

characteristics nor and ccommorbidities

and of course

looking into artificial logic mechanism of angina

hence leading us to select the better options of anti

anginal agents depending on the metabolic profile

hemodynamic profile at certain comrbidities

so again example for patients with diabetes

the possible option can be um

giving your retholazine burapamine

evaporating trimetasidine

or your long acting nitrates in some data blockers

making contraindicated in the substance of patients

that's why we consider

other safe agents in this population

so we need to have at least

make sure that we use drugs that have

not only benefit as an anti anginal agent

but may also have an additional benefit

in reducing blood sugar level

so we just show here

the effect of renolyzine

in diabetics with stable angina

as a result of the Teresa trial

wherein they look at subsets of patients with type 2

diabetes and underlying C a

d who were symptomatic

despite treatment with anti anginal agents

and you can see here

that patients who are receiving renolyzine

have actually reduction from baseline

in their mean number of anginal attack per week

and means of lingual nitroglycerine consumption

it also

resulted in a significant reduction in their HVA1C

by almost nearly 1% compared to placebo

so if you have a patient with diabetes

and you want to manage their angina

and you also want or looking for a drop

with significant production in their HVA 1 c

knowing that diabetes control

is also an important risk factor

and target

among patients with chronic coronary syndrome

then maybe adding

or considering renolazine is a wise option

because of the result of this trials

there is also a result uh that comes from the

from the study the Merlin PM thirty six

going to ask a significant reduction in H B

a 1 c compared to those patients with no diabetes

and this is clinically significant

or meaningful reduction in H B

a 1 c among those patients who were certified with

according to diabetes status

and who were receiving red dollars in

so in the Severus meta analysis published in 2,013

looking at the results

of patients who were included in Carissa Merlin

Demetrial

on substance of patients with diabetes

they found out that those patients were taking

retholazine

actually resulted in better anginal reduction

and HVA 1 c reduction as well

and the possible mechanisms of renologous

glycemic effect

is attributed by its effect on the pancreatic

alpha cells reduced

seeing the glucagon release

and also

a significant effect in their endothelial and smooth

muscle cells so

if you can see the effect of sgility to inhibitors

on the isogen channels

not reducing the blood sugar Red Level

the rebologies also significantly reduce isogen uh

channels no

it may affect this as a possible mechanism of its anti

or hip hypoglycemic effect okay

so in addition to that

it also have a good coronary microvascular um

function uh benefit so the clinically uh

the clinical outcomes

not related to the use of renolazine is

there is a significant reduction in recurrence chemia

although it did not achieve the primary

outcome of reduction in cardiovascular death

and MI when compared with placebo

the long term outcomes of renolazine

in patients with refractory angina

based on this trial resulted

significant improvement in their anginal attacks not

and also resulted in fewer hospitalization

due to anginal frequency

and revascularization rates was likewise reduced

which also translates in reduction in overall cost

among patients with stableschemic heart disease

as seen in this real world analysis of hundred

eight thousand patients

with stakeable coronary artery disease

therefore this is also a good um

option in patients who are taking renolyzine

for patients with stable coronary artery disease

and was proven to be cost effective

resulting in less revascularization

and reduction in all costs

in cardiovascular related health care utilization

compared to

those patients were just taking beta blockers

and Calcium channel blockers

or nitrates so

let me end by emphasizing that optimal management

consist of interventions to improve prognosis

and quality of life and for those patients with staple

chronic coronary syndrome

optimal medical therapy is non inferior

thirtyvascularization

in decreasing cardiovascular death

and should be emphasized in the treatment option

for patients with c a B

and this Reno

and renolazine has been proven to be advantageous

in its role in relieving angina

improving quality of life

without effect on hemodynamics

with an additional benefit of reducing HVA1C

and was seen to have a good side effect profile

and cost effective

so thank you very much for your kind attention