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Aims Spinal cord stimulation (SCS) is a treatment for patients with refractory angina pectoris (RAP) who remain symptomatic despite optimal medical therapy and without revascularisation options. Previous studies have shown that SCS improves the quality of life in this patient group and reduces the severity of the angina pectoris. The aim of this prospective, singlearm observational study is to show this effect in a single-centre cohort using a multidisciplinary team approach to the selection process, with a follow-up period of 1 year. Methods and results Between July 2010 and March 2017, 87 patients with RAP referred to our centre received SCS. The Seattle Angina Questionnaire (SAQ) and RAND 36-Item Health Survey (RAND-36) were completed at baseline, prior to implantation, and 1 year post-implantation. After 1 year of followup there was a statistically significant decrease in the frequency of angina pectoris attacks from more than 4 times a day to 1-2 times a week (p < 0.001). The SAQ showed statistically significant improvement in four of the five dimensions: physical limitation (p < 0.001), angina frequency (p < 0.001), angina stability (p < 0.001) and quality of life (p < 0.001). The RAND-36 showed statistically significant improvement in all Electronic supplementary material The online version of this article (

Background COVID-19 is a novel disease that has been associated with changes in haemostasis and increased risk of thrombosis, especially in patients who are critically ill. Case summary a 71-year-old patient presented to the emergency department with acute respiratory failure. The patient had been discharged from the hospital 1 day before, after apparent recovery of a proven COVID-19 infection. Relevant medical history reports polycythemia vera. The diagnostic work-up included a CT-scan of the thorax, revealing bilateral sub-segmental pulmonary embolism. An echocardiogram showed a dilated right ventricle with poor systolic function and a large multi-lobar thrombus. Forty-eight hours after initiation of treatment with therapeutic anticoagulation the thrombus was no longer seen on the echocardiogram. Discussion This case confirms the high risk of thrombosis in COVID-19 infection as has been described in recent literature. It demonstrates the severity of the coagulopathy given the presence of both bilateral sub-segmental pulmonary embolism and right ventricular thrombus, despite treatment with prophylactic anticoagulation. Remarkable in this case is the fact that the patient had a myeloproliferative neoplasm (polycythaemia vera). This is associated with an increased risk of thrombosis, especially in the presence of erythrocytosis, leucocytosis, and/or inflammation.

The timely revascularization of an occluded coronary artery is the cornerstone of treatment in patients with ST-elevation myocardial infarction (STEMI). As essential as this treatment is, it can also cause additional damage to cardiomyocytes that were still viable before reperfusion, increasing infarct size. This has been termed “myocardial reperfusion injury”. To date, there is still no effective treatment for myocardial reperfusion injury in patients with STEMI. While numerous attempts have been made to overcome this hurdle with various experimental therapies, the common denominator of these therapies is that, although they often work in the preclinical setting, they fail to demonstrate the same results in human trials. Hypothermia is an example of such a therapy. Although promising results were derived from experimental studies, multiple randomized controlled trials failed to do the same. This review includes a discussion of hypothermia as a potential treatment for myocardial reperfusion injury, including lessons learned from previous (negative) trials, advanced techniques and materials in current hypothermic treatment, and the possible future of hypothermia for cardioprotection in patients with STEMI.

The number of patients with coronary artery disease (CAD) who have persisting angina pectoris despite optimal medical treatment known as refractory angina pectoris (RAP) is growing. Current estimates indicate that 5 to 10% of patients with stable CAD have RAP. In absolute numbers there are 50,000 to 100,000 new cases of RAP each year in the United States and 30,000 to 50,000 new cases each year in Europe. The term RAP was formulated in 2002. RAP is defined as a chronic disease (more than three months) characterized by diffuse coronary artery disease in the presence of proven ischemia which is not amendable to a combination of medical therapy, angioplasty or coronary bypass surgery. There are currently few treatment options for patients with RAP. One such last-resort treatment option is spinal cord stimulation (SCS) with a Class of recommendation IIB, level of evidence B in the 2019 European Society of Cardiology Guidelines for the diagnosis and management of chronic coronary syndromes. The aim this review is to give an overview of neuromodulation as treatment modality for patients with RAP. A comprehensive overview is given on the history, proposed mechanism of action, safety, efficacy and current use of SCS.