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.

Efficacy Compared With Other Treatment Modalities

As there is a lack of distinct patient selection criteria for the different treatment options for refractory angina, direct comparisons of efficacy on cost–effectiveness are difficult. However, we believe the available comparative studies add important information.

The systematic review and meta-analysis by Taylor et al. , published in 2009, concludes that SCS is an effective and safe treatment option for the management of refractory angina pectoris.^[36] In addition, SCS was found to be of similar efficacy and safety to the treatment alternative of PMR. The authors concluded that the results of the meta-analysis support the current treatment recommendations (AHA/American College of Cardiology) regarding SCS in severe angina pectoris, and thereby also supports the more widespread use of SCS for the management of refractory angina.^[36]

A third, recent UK review, published in Health Technology Assessment, concluded that for severe angina pectoris, SCS was more effective than PMR at 3 months, but not at 12 months, in increasing the time to angina, while the effect on quality of life were similar.^[47] According to this review, SCS is more effective than no SCS/inactive device in delaying time to angina and reducing nitrate consumption (symptom relief), as demonstrated in the short-term follow-up.^[47]

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

Abstract and Introduction
Severe Angina Pectoris: A Moving Target?
Patient Characteristics
Treatment of Refractory Angina Pectoris
SCS in Severe Angina Pectoris: Mechanisms
Efficacy of SCS in Severe & Refractory Angina Pectoris
Efficacy Compared With Other Treatment Modalities
Cost–effectiveness of SCS in Severe Angina Pectoris
Future Perspective
Conclusion
References
Sidebar

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?

Efficacy Compared With Other Treatment Modalities

Tables

References

Authors and Disclosures