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.

Treatment of Refractory Angina Pectoris

Due to the challenging pain problem, refractory angina is clinically important not only for the cardiologist, but also for other specialists such as in acute medicine, anesthesiology and pain medicine. Patients with refractory angina pectoris are greatly limited in daily function by having severe symptoms of chest discomfort and/or pain at slight effort or even at rest. The patients are frequently hospitalized and have severely impaired quality of life.^{[12,16,17,19]}

Additional treatment modalities for refractory angina, are therefore needed. Only a few of the additional treatment modalities, which includes TENS, SCS, endoscopic thoracoscopic sympathectomy, thoracic epidural anesthesia, transmyocardial and percutaneous myocardial laser revascularization (PMR), stem cell therapy and enhanced external counterpulsation, available for refractory angina, have been extensively studied in high-quality studies.^[4] Recently, several new possible pharmacological treatment alternatives have emerged, such as selective sinus node I_f channel inhibitors and fatty acid metabolism inhibitors. These promising methods need to be further evaluated, and are not part the current guidelines from European Society of Cardiology and American Heart Association (AHA).^[3,4]

Based on available data, SCS is today considered the first-line treatment for refractory angina by the Joint Study Group for refractory angina of the European Society of Cardiology.^[4] The current AHA/American College of Cardiology updated guidelines on the management of patients with chronic stable angina pectoris, gives SCS a level B recommendation, based on grade IIb evidence.^[3]

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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?

Treatment of Refractory Angina Pectoris

Tables

References

Authors and Disclosures