12/26/2023 0 Comments A nuclear paradigm shiftThe attention-grabbing dripline lessons we address are rooted in emergent degrees of freedom involving cluster constituents. The challenges at driplines may appear less dramatic than what calls for a Kuhnian turnover, still we hope to convey that valuable lessons may be learned. Recent discoveries in halo nuclei, \(^\)C will serve as our cardinal examples. With restriction to new forms of transient cold nuclear matter, we will address if and how new discoveries have influenced the way we think about nuclear architecture, drawing parallels with comparable development in other branches of science. Following Rutherford’s paradigm, nuclear physics has developed by colliding nuclei and from studying the fragments that emerge. At the centennial for the nuclear atom, it may be appropriate to address the current paradigmatic situation for nuclear physics on background of the large investments made during the last decades. Proven secondary prevention strategies and lifestyle interventions in contemporary goal-directed medical therapy continue to be underutilized, particularly in the United States, where as few as 40-50% of eligible CAD subjects are treated according to established clinical practice guidelines, including those who have been revascularized.įinally, pharmacologic and procedural approaches to stable ischemic heart disease are complementary, and integrating these can optimize outcomes.Science is-as emphasized 50 years ago by Thomas Kuhn in his academic bestseller The Structure of Scientific Revolutions-driven by paradigms, rooted in outstanding discoveries and practice. We also need to invest in developing newer management strategies and health care delivery models that may better align with treatments proven to benefit patients and society.Ī conservative approach to management, including noninvasive testing, lifestyle interventions, and goal-directed multifaceted medical therapy, is evidence based and often effective in patients with stable angina. Such additional diagnostic testing should be performed only after obstructive CAD has been excluded and only if symptoms do not improve (or if they worsen) despite appropriate antianginal therapy of ≥2 drug classes. In patients without obstructive stenosis, the functional assessment of coronary circulation, including acetylcholine testing for spasm, coronary flow reserve, and microvascular resistance, may be considered to guide subsequent pharmacologic treatment. There is a need for a more inclusive management paradigm that uncouples the singular association between epicardial CAD and revascularization and better aligns diagnostic approaches that tailor treatment to the underlying mechanisms and precipitants of angina and ischemia in contemporary clinical practice. However, the role of revascularization in reducing long-term cardiac events in these patients has been limited mainly to those with left main disease, three-vessel disease with diabetes, or decreased ejection fraction.Įvolving evidence indicates that nonepicardial coronary causes of angina and ischemia, including coronary microvascular dysfunction, vasospastic disorders, and derangements of myocardial metabolism, are more prevalent than flow-limiting stenoses, raising concerns that many important causes other than epicardial CAD are neither considered nor probed diagnostically.Īssessments of ischemia that do not delineate abnormal coronary angiographic findings should not necessarily shift diagnostic and therapeutic considerations to noncardiac causes of angina but rather to exploring nonepicardial coronary causes (e.g., coronary microvascular disease and vasospastic disorders). Management of stable coronary artery disease (CAD) or chronic coronary artery disease has been based on the assumption that flow-limiting atherosclerotic obstructions are the proximate cause of angina and myocardial ischemia in most patients and represent an important target for revascularization. The following are key points to remember from this review on the evolving management paradigm for stable ischemic heart disease patients:
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