Spinal Cord Stimulation for Long-term Treatment of Severe Angina Pectoris

What Does the Evidence Say?

Mats Börjesson; Paulin Andréll; Clas Mannheimer

Future Cardiol. 2011;7(6):825-833.

Conclusion

Future anticipated changes in lifestyle-related risk factors, new additional alternative therapeutic options as well as widened treatment indications, will affect the population of refractory angina patients, both in numbers and possibly in characteristics (more peripheral coronary artery disease in patients with diabetes). While treatment options will surely continue to improve in efficacy and lower the current pool of refractory patients, a growing number of new patients with refractory angina are anticipated, due to the increasing lifestyle related global atherosclerotic burden.

Thus, many patients in need of additional efficacious treatment options for severe, disabling angina will also be present in the future. There is scientific evidence for SCS giving rise to symptomatic benefits (decrease in anginal attacks) and improved quality of life, as well as improved functional status (improved exercise time on treadmill or longer walking distance without angina) in patients with severe angina pectoris.^[35] In addition, limited data support that SCS does not seem to have any negative effects on mortality in patients with refractory angina pectoris with a low complication rate.^[35]

While future studies regarding the effect of SCS on myocardial ischemia and heart failure might further enlarge the target population for SCS treatment, the most important future challenge may be to define the patient selection procedure and establish clear indications for SCS. Long-term efficacy studies and cost–effectiveness studies are needed to establish and to possibly move SCS up the treatment ladder of severe angina pectoris.

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Financial & competing interests disclosure
Paulin Andréll and Clas Mannheimer have received honoraria for talks in this field, by Medtronic Inc. and St Jude Medical. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Cite this: Spinal Cord Stimulation for Long-term Treatment of Severe Angina Pectoris - Medscape - Nov 01, 2011.

Table 1. Refractory angina pectoris patient characteristics.
	TenVaarwerk et al., (1999)¹⁵ (n = 510)	Di Pede et al., (2003)¹⁶ (n = 104)	Andréll et al., (2011)¹² (n = 139)	Andréll et al, (2010)¹⁷ (n = 235)
Mean age (years)	64	69	70	69
Men/women	367/150 72/28%	70/34 67/33%	101/38 73/27%	181/54 77/23%
Current smokers (%)	21	33	9	NA
*Concomitant diseases*
Previous myocardial infarction (%)	66	64	64	71
Previous CABG (%)	58	46	54	75
Previous PCI (%)	17	37	27	50
Hyperlipidemia (%)	28	52^†	54	66
Hypertension (%)	39	52	50	59
Diabetes mellitus (%)	NA	27	32	37
LVEF <40% (%)	24	NA	NA	16
*Pharmacological treatment*
β-blockers (%)	66	60	90	92
Calcium antagonists (%)	73	75	25	47
Long-acting nitrates (%)	79	NA	74	86
Lipid-lowering drug (%)	NA	NA	72	82
Aspirin/other platelet inhibitor (%)	NA	91	92	86
ACE inhibitors/ARB (%)	25^‡	42^‡	43	59

Executive Summary

Severe Angina Pectoris: A Moving Target (Epidemiology)

The future group of patients with refractory angina pectoris will be different from today's patients and represent a 'moving target' as risk factors, efficacy of treatment and indications continue to change.
Even if a greater number of patients who previously were considered to suffer from end-stage coronary artery disease might be eligible for revascularization procedures, and no longer 'refractory', a large number of patients suffering from refractory angina pectoris still remain.

Patient Characteristics (Demographics)

Previous reports have indicated that patients with refractory angina pectoris have a cardiac annual mortality of approximately 5%.

Treatment Options

Based on available data, spinal cord stimulation (SCS) is today considered as first-line treatment for refractory angina by the Joint Study Group of the European Society of Cardiology.
In the future, if further studies on long-term efficacy, patient selection and cost–effectiveness are positive, SCS has the potential to be moved up the treatment ladder for severe angina.

SCS in Severe Angina Pectoris (Mechanism of Action)

Spinal cord stimulation has an anti-ischemic effect, which has been demonstrated in a number of short-term studies from different centers. The anti-ischemic effect seems to be due to decreased myocardial oxygen consumption rather than due to an effect on myocardial blood flow.

Efficacy of SCS in Refractory Angina

There is strong evidence for SCS giving rise to symptomatic benefits (decrease in anginal attacks) and improved quality of life, in patients with severe angina pectoris. There is also strong evidence for SCS improving the functional status of patients with refractory angina, as illustrated by improved exercise time on treadmill or longer walking distance without angina.

Cost–effectiveness of SCS in Severe Angina

According to a limited number of studies, SCS seems to be a cost effective treatment modality with a 'break-even' after approximately 15–16 months. The foremost reason to the cost–effectiveness of SCS seems to be due to decreased hospital admissions.

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Spinal Cord Stimulation for Long-term Treatment of Severe Angina Pectoris

What Does the Evidence Say?

Conclusion

Tables

References

Authors and Disclosures