Treatment of refractory angina in patients not suitable for revascularization

Abstract

A growing number of patients, particularly those with advanced, chronic coronary artery disease, experience symptoms of angina that are refractory to treatment with β-blockers, calcium-channel blockers, and long-acting nitrates, despite revascularization. The management of patients with refractory angina who are unsuitable for further revascularization is strikingly different across the world, and is contingent on local resources and available expertise. Mortality in this patient population has decreased, but enhancing quality of life remains a challenge. New treatment principles are emerging in current practice, such as metabolic modulation, therapeutic angiogenesis, and novel interventional techniques (coronary in-flow redistribution and approaches to chronic total occlusion). The contemporary management of refractory angina encourages individualized, patient-centred care in interdisciplinary, specialized clinics. Global initiatives are required to address complex clinical problem-solving for patients with refractory angina. In this Review, we discuss the epidemiology of refractory angina, and provide an update on the pharmacological, noninvasive, and interventional options that are available to these patients or are under development.

Neovascularization Potential of Blood Outgrowth Endothelial Cells From Patients With Stable Ischemic Heart Failure Is Preserved

“…In patients with ischemic heart disease, refractory to optimal medical treatment and percutaneous or surgical revascularization, progenitor cell transfer may constitute a promising biological alternative (“biological bypass”) 6. Autologous BOECs are able to induce neovascularization not only by incorporation into functional vessels, but also through paracrine modulation 7, 8…”

Repeat Cell Therapy for Refractory Angina

“…[1][2][3] Previous studies suggested that up to 15% of patients undergoing catheterization are suboptimal candidates for further revascularization. 4 This number may be growing because a recent analysis from the Duke Databank for Cardiovascular Disease found that 25% of patients had Canadian Cardiovascular Society (CCS) class II-IV angina and coronary disease not amenable to further revascularization.…”

“…5 Contemporary data suggest that mortality in these complex patients is decreasing, despite the significant burden of coronary artery disease, whereas rehospitalization rates and resource utilization remain high, reflecting the poor quality of life and functional status in these patients. 1,3,6 See Article by Mann et al Limited treatment options are available for patients with refractory angina beyond pharmacological treatment and revascularization. This unmet clinical need has stimulated the investigation of novel treatment options, including advanced techniques to treat chronic total occlusions, neuromodulation, reduction of the coronary sinus, shockwave therapy, and stem cell therapy.…”

“…This unmet clinical need has stimulated the investigation of novel treatment options, including advanced techniques to treat chronic total occlusions, neuromodulation, reduction of the coronary sinus, shockwave therapy, and stem cell therapy. 1,3 Because the primary problem for these patients is inadequate myocardial perfusion, stem cell therapy using angiogenic progenitors represents a theoretically attractive approach. Initial trials for this specific indication have arguably been the most positive in the field of stem cell therapy.…”

Coronary Venous Interventions

“…As many as 7% or 1.8 million individuals are estimated to be unrevascularizable and the treatment options for these patients are limited and often unsuccessful. 2,3 Recently, several articles have been published suggesting that retrograde perfusion via the coronary sinus may have promise as a treatment option for these patients.…”