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.

Patient Characteristics

Approximately 67–77% of the patients with refractory angina pectoris are men and the average age is 64–70 years (Table 1).^[15–17] The majority of the patients have previously suffered from a myocardial infarction (64–71%) and have previously undergone a revascularization procedure (64–88%), according to the same studies.^[12,15–17] The patients have usually suffered from angina for approximately 7–8 years before being considered as having refractory angina and consequently have been subjected to additional symptomatic treatment modalities, including transcutaneous electrical nerve stimulation (TENS),^[18] standard analgetics and/or spinal cord stimulation (SCS).^[15,16] Studies have demonstrated that patients with refractory angina pectoris have surprisingly well preserved left ventricular ejection fraction (LVEF), with only a subgroup of patients showing a low LVEF.^[12,15–17] Previous reports have indicated that patients with refractory angina pectoris have a cardiac annual mortality of approximately 5%.^[8,9,15,17]

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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?

Patient Characteristics

Tables

References

Authors and Disclosures