Management of Angina Pectoris: The Role of Spinal Cord Stimulation

Siegfried Eckert; Dieter Horstkotte

Disclosures

Am J Cardiovasc Drugs. 2009;9(1):17-28. 

In This Article

Abstract and Introduction

Abstract

Progress in prevention as well as drug and interventional therapy has improved the prognosis of patients with cardiovascular disorders. Many patients at risk have advanced coronary artery disease (CAD), have had multiple coronary interventions, and present with significant co-morbidity. Despite adequate risk factor modulation and often several revascularization procedures, some of these patients still have refractory angina pectoris. Apart from advanced CAD and insufficient collateralization, the cause is often endothelial dysfunction. For this situation, one treatment option is neuromodulation. Controlled studies suggest that, in patients with chronic refractory angina pectoris, spinal cord stimulation (SCS) provides a relief from symptoms equivalent to that provided by surgical therapy, but with fewer complications and lower rehospitalization rates. SCS may result in significant long-term pain relief with improved quality of life. In patients with refractory angina undergoing SCS, some studies have shown not only a symptomatic improvement, but also a decrease in myocardial ischemia and an increase in coronary blood flow. Discussion is ongoing as to whether this is a direct effect on parasympathetic vascodilation or merely a secondary phenomenon resulting from increased physical activity following an improvement in clinical symptoms. Results from nuclear medical studies have sparked discussion about improved endothelial function and increased collateralization. SCS is a safe treatment option for patients with refractory angina pectoris, and its long-term effects are evident. It is a procedure without significant complications that is easy to tolerate. SCS does not interact with pacemakers, provided that strict bipolar right-ventricular sensing is used. Use in patients with implanted cardioverter defibrillators is under discussion. Individual testing is mandatory in order to assess optimal safety in each patient.

Introduction

Therapeutic options for the management of angina pectoris in patients with coronary artery disease (CAD) have improved over the past 2 decades. Nevertheless, angina pectoris is a common and important symptom affecting many patients with CAD, as well as some with endothelial dysfunction.

Despite optimal drug therapy and no option for coronary revascularization procedures (percutaneous coronary intervention [PCI] or aortocoronary bypass [ACB]), some patients with CAD have persistent angina pectoris class III or IV according to the Canadian Cardiovascular Society (CCS).[1] The treatment of these patients with non-responding angina pectoris presents a medical challenge. We have no accurate figures on the occurrence and frequency of refractory angina, nor is the prevalence of angina pectoris known in most communities. The overall prevalence of patients referred for coronary angiography with refractory angina varies from 5% to 15%.[2]

Various treatment concepts have been developed for patients with therapy-resistant angina pectoris and have been applied in clinical studies: long-term intermittent urokinase therapy,[3] surgical and percutaneous transmyocardial laser revascularization,[4,5,6] enhanced external counterpulsation,[7,8] percutaneous in situ coronary venous arterialization,[9] and transcutaneous electrical nerve and spinal cord stimulation (SCS).[10,11,12,13,14,15,16,17,18,19] The latter has been established as the most applicable. It is recommended as the therapy of choice by the European Society of Cardiology Joint Study Group on the Treatment of Refractory Angina.[2]

In this article, we review the role of SCS in the management of severe angina pectoris in patients with ischemic heart disease and endothelial dysfunction.

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