Management of Refractory Angina Pectoris

Abstract

Refractory angina (RA) is conventionally defined as a chronic condition (≥3 months in duration) characterised by angina in the setting of coronary artery disease (CAD), which cannot be controlled by a combination of optimal medical therapy, angioplasty or bypass surgery, and where reversible myocardial ischaemia has been clinically established to be the cause of the symptoms. 1 In clinical practice, patients diagnosed with RA are a heterogeneous group; common among them, however, is that they remain significantly limited by persistent debilitating chest discomfort despite optimised conventional therapy. In many cases, functional imaging may not demonstrate myocardial ischaemia. It is important to recognise that irrespective of aetiology, patients with refractory chest discomfort often attribute their symptoms to be cardiac in origin and believe that they may herald a life-threatening cardiac event. This predisposes to a progressive decline in their mental wellbeing and increasing anxiety whereby pain begets pain. Consequently, patients can develop persistent symptoms and pessimistic health beliefs, translating to negative behaviours and an impaired quality of life. In this regard, a shift in our approach of RA to that of managing a 'chronic chest pain syndrome' may help us not only to better appreciate the multifactorial aetiologies that are in operation in any given patient but also encourage the use of a holistic approach to manage these patients more effectively. Epidemiology Precise estimates of the prevalence and incidence of RA are not available; however, several sources suggest that this is a large and growing problem. 2,3 Variations in definition and clinical heterogeneity of patients labelled with a diagnosis of RA significantly complicate such endeavours. Data from the Canadian Community Health Survey (2000-2001) suggest that ~500,000 Canadians are living with unresolved angina. 4 The proportion of these patients with true RA is unknown. 5 In the US, it is estimated that between 600,000 and 1.8 million patients have RA, with approximately 75,000 new cases diagnosed each year. 5,6 In Europe, the annual incidence of RA is estimated at 30,000-50,000 new cases per year. 1,7 Specific figures for the UK are lacking and further work to define the burden of RA in the UK population is needed. However, if the results shown by Williams et al., who found that 6.7 % of patients undergoing angiography in a contemporary cohort had no revascularisation option, are applied to the 247,363 angiograms performed in England in 2014, it can be estimated that ~16,500 new cases of RA may occur in England per year. 3,8 Given improvements in CAD-related survival and increasing age of the population, together with an increasing appreciation from the contemporary Outcome of Percutaneous Coronary Intervention for Stent ThrombosIs Multicentre Study (OPTIMIST) registry that the long term prognosis of RA is not as bad as previously thought, the incidence and prevalence of RA is only set to rise. 5,6,9,10 Furthermore, it has also been r...

Predictors of treatment benefits after enhanced external counterpulsation in patients with refractory angina pectoris

“…Patients with refractory angina pectoris (RAP) experience chronic symptoms, characterized by chest pain, in the setting of coronary artery disease (CAD), which is uncontrolled despite optimized therapy 1,2 . In the European guidelines CAD is categorized as either acute coronary syndrome or chronic coronary syndrome, with RAP in the latter category 3 .…”

“…The prevalence of RAP is 5–10% in stable CAD, 4‐5 with a yearly incidence of 50 000–100 000 in the US and 30 000–50 000 in Europe 4,6 . This heterogeneous group remains significantly limited in daily life despite revascularization and optimized medication 2 . Many are not considered for further revascularization when deteriorating in angina symptoms due to unsuitable anatomy, a negative risk–benefit profile, or advanced age 4 .…”

Subdural Cervical Spinal Cord Stimulator Lead Placement Leading to Progressive Neurologic Symptoms

“…For chronic angina pain, treatment will typically involve conservative options, such as lifestyle modifications and pharmacologic therapies. Medications may include beta-blockers, calcium channel blockers, and other vasodilators, in addition to less common medications (4). It is worth mentioning, however, that no prior placebo-controlled randomized controlled trial has shown significant improvement in symptoms or quality of life in this patient population.…”

A Cure of Coronary Artery Disease by Removing Atheromatous Plaques from Coronary Arteries in a Diabetic Patient

“…This the first time that a patient has been treated with pharmacological intervention to cure coronary artery disease, the patient had CABG and PTCA but also had refractory angina [3,4]. Patient was not advised PTCA or CABG by her cardiologist after last angiogram [1,5,6].…”