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Treatment options for refractory angina in patients who are not candidates for revascularization

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Abstract

Patients with refractory angina are those for whom medical therapy has failed to eradicate the angina completely and who have persistent symptoms that are stable but limit their activities of daily living. Approach to management must include the elimination of the secondary causes of this condition and maximum medical therapy, and if angina persists, the consideration of other strategies. Controversy exists regarding the value of transmural myocardial laser revascularization. Enhanced external counterpulsation is clinically effective in approximately 70% of patients. Spinal cord stimulation is not being used clinically in the United States. In the United States, it is still an investigational procedure that is currently being evaluated prospectively in a randomized trial. Ranolazine, an inhibitor of sodiumdependent calcium overload, may prove to be useful in patients with refractory angina.

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References and Recommended Reading

  1. • Conti CR: The ABCs of modern management of chronic stable angina. Clin Cardiol 2005, 28:109–110.This summarizes the current recommendations for aggressive therapy of chronic myocardial ischemia

    PubMed  Google Scholar 

  2. • Allen KB, Dowling RD, Fudge TL, et al.: Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina. N Engl J Med 1999, 341:1029–1036.This is one of the positive articles written in favor of TMR

    Article  PubMed  CAS  Google Scholar 

  3. • Hillis LD, Lange RA: Transmyocardial laser revascularization. N Engl J Med 1999, 341:1075–1076.This is a cautionary look at TMR in chronic angina patients

    Article  PubMed  Google Scholar 

  4. • Arora RR, Chou TM, Jain D, et al.: Multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol 1999, 33:1833–1840.This is the classic study of EECP

    Article  PubMed  CAS  Google Scholar 

  5. • Michaels AD, Linnemeier G, Soran O, et al.: Two-year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]. Am J Cardiol 2004, 93:461–464.This is another positive long-term positive study for EECP

    Article  PubMed  Google Scholar 

  6. • Conti CR: EECP-enhanced external counterpulsation. J Am Coll Cardiol 1999, 33:1841–1842. This is an objective assessment of EECP in patients with chronic stable angina

    Article  PubMed  CAS  Google Scholar 

  7. • Eliasson T, Augustinsson LE, Mannheimer C.: Spinal cord stimulation in severe angina pectoris — presentation of current studies, indications and clinical experience. Pain 1996, 65:169–179.This is an excellent review of the benefits of SCS in patients with chronic angina

    Article  PubMed  CAS  Google Scholar 

  8. • Mannheimer C, Augustinsson LE, Carlsson CA, et al.: Epidural spinal electrical stimulation in severe angina pectoris. Br Heart J 1988, 59:56–61.This study shows decreased symptoms but also decreased evidence for myocardial ischemia (ST-segment depression during exercise)

    PubMed  CAS  Google Scholar 

  9. • DeJongste M, Haaksma J, Hautvast R, et al.: Effects of spinal cord stimulation on myocardial ischemia during daily life in patients with severe coronary artery disease. Br Heart J 1994, 71:413–418. This article shows a decrease in ST-segment depression during activities of daily living

    CAS  Google Scholar 

  10. • Lasagna L, Mosteller F, Felsinger J, et al.: A study of the placebo response. Am J Med 1954, 16:770–779.This is a classic that needs to be read by all clinical trialists

    Article  PubMed  CAS  Google Scholar 

  11. •• Mannheimer C, Eliasson T, Augustinsson LE, et al.: A. electrical stimulation versus coronary artery bypass surgery in severe angina pectoris. The ESBY study. Circulation 1998, 97:1157–1163.These data reflect favorably on SCS to relieve myocardial ischemia

    PubMed  CAS  Google Scholar 

  12. • ten Vaarwerk IAM, Gessurun GHA, DeJongste MJL, et al.: for the Working Group on Neurocardiology: Clinical outcome of patients treated with spinal cord stimulation for therapeutically refractory angina pectoris. Heart 1999, 82:82–88.Data are positive for SCS and long-term benefit in patients with chronic angina

    Google Scholar 

  13. • Undrovinas AI, Undrovinas NA, Belardinelli L, et al.: Henry Ford Heart and Vascular Institute, Detroit MI, CV Therapeutics, Palo Alto, CA: Ranolazine inhibits late sodium current in isolated left ventricular myocytes of dogs with heart failure. J Am Coll Cardiol 2004, Abstract 1068-128. Shows that ranolazine is a selective inhibitor of the late sodium current

  14. • Chaitman BR, Skettino SL, Parker JO, et al.: MARISA Investigators: Anti-ischemic effects and long-term survival during ranolazine monotherapy in patients with chronic severe angina. J Am Coll Cardiol 2004, 43:1375–1382.Randomized clinical trial of ranolazine to show efficacy and safety versus placebo

    Article  PubMed  CAS  Google Scholar 

  15. • Chaitman BR, Pepine CJ, Parker JO, et al.: Combination Assessment of Ranolazine In Stable Angina (CARISA) Investigators; Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004, 291:309–316.Randomized clinical trial of ranolazine to show efficacy versus usual antiangina therapy

    Article  PubMed  CAS  Google Scholar 

  16. • Belardinelli L, Antzelevitch C, Fraser H: Inhibition of late (sustained/persistent) sodium current: a potential drug target to reduce intracellular sodium-dependent calcium overload and its detrimental effects on cardiomyocyte function. Eur Heart J 2004, 6(Suppl 1):13–17.Shows the disruption of cellular sodium and calcium homeostasis related to ischemia

    Google Scholar 

  17. • Antzelevitch C, Belardinelli L, Zygmunt AC, et al.: Electrophysiological effects of ranolazine, a novel antianginal agent with antiarrhythmic properties. Circulation 2004, 110:904–910. The beneficial effects of ranolazine relates to its effect on intracellular sodium and calcium.

    Article  PubMed  CAS  Google Scholar 

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Correspondence to C. Richard Conti MD.

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Conti, C.R. Treatment options for refractory angina in patients who are not candidates for revascularization. Curr Cardiol Rep 8, 272–276 (2006). https://doi.org/10.1007/s11886-006-0058-2

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