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. 

In This Article

Future Perspective

The efficacy of SCS in the management of severe angina, has been shown in several recent reviews.[35,36,47] For SCS to be regarded as a routine treatment modality for severe angina pectoris, several future challenges remain:

  • More randomized studies on the long-term efficacy of SCS, are needed.

  • Further studies on proper patient selection procedures are also needed.[46] The ideal patient for SCS is not defined at present. To select patients, suitable for SCS (i.e., those who would benefit the most and therefore potentially make SCS more cost effective), is essential. A future goal would be to define the 'gold standard' of tests, for instance to rule out and confirm ischemia, as part of this selection process. Improved patient selection will affect the patient exclusion and inclusion criteria, where confirmed relationship between ischemia and symptoms would be required (to rule out other causes of angina-like pain), while more patients without prognostic benefit from surgical interventions may in the future be suitable for SCS treatment.

  • Approximately 80% of the patients respond to SCS treatment after undergoing screening according to local protocols.[17,49] These protocols might involve psychological screening, screening with TENS or temporary electrodes. However, the diagnostic value of these screening modalities have not yet been systematically studied and hence, there are no guidelines available regarding how to identify responders to SCS treatment prior to implantation. To date, no objective variables arer available for assessment in order to determine responders to SCS treatment in angina pectoris. Thus, further studies regarding proper screening procedure are warranted.

  • Health-related quality of life measures, using validated instruments, could improve future cost–effectiveness analyses, which are needed for SCS to be accepted as part of the routine management of severe and refractory angina pectoris.

  • Clinical trials aim to identify interventions to benefit future patients. Interventions should either prevent premature death or improve health-related quality of life. Patient reported outcomes allow measurement of the effect of interventions from the patient's perspective and might be a useful tool, particularly when interventions aim to improve symptoms and functional status.[53] Since the main effects of SCS treatment in severe and refractory angina are symptom relief, improved functional status and increased quality of life it is of great importance to also include patient reported outcome assessments regarding the effect of treatment. Currently there are few data available in patients with severe or refractory angina pectoris.

  • Another aspect of SCS treatment in angina patients that needs to be elucidated is the effect on physical function. According to clinical experience, patients who receive SCS treatment increase their physical activity. This clinical observation is in line with results from studies reporting improved functional status on exercise ECG and improved physical function according to quality of life questionnaires.[17,20] In previous studies, the positive long-term symptomatic effects of SCS have been interpreted as secondary to increased physical activity.[54] However, to date there are no availabe large systematic studies regarding the effect on physical function of SCS treatment in angina pectoris.

  • During recent years, results from animal studies have indicated that SCS has a protective effect in induced myocardial infarction as well as in heart failure in terms of decreased myocardial ischemia, decreased myocardial infarction size, less ventricular arrhythmias and improved LVEF.[29,33,55,56] It would be of great interest to apply these results in human studies and add new indications for SCS treatment.


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