Acupuncture Shows Promise in Chronic Stable Angina

Megan Brooks

July 29, 2019

Acupuncture may help alleviate angina symptoms when added to antianginal medication in patients with chronic stable angina (CSA), results of a multicenter study conducted in China suggest.

Acupuncture administered three times weekly on acupoints in the disease-affected meridian (DAM) was superior to that in the nondisease affected meridian (NAM), sham acupuncture (SA), and no acupuncture (the wait-list group) in reducing angina attacks.

"To our knowledge, our study is the largest multicenter clinical trial to show the beneficial effect of true acupuncture as adjunctive treatment for CSA within 16 weeks and is the first to explore acupoint specificity in this field," Fanrong Liang, MD, and colleagues from Chengdu University of Traditional Chinese Medicine in Chengdu, conclude in their report.

"We found that acupuncture on the DAM had superior and clinically relevant benefits in reducing angina frequency and pain intensity to a greater degree than acupuncture on a NAM, SA, or no acupuncture."

"This is a promising study," Prashant Vaishnava, MD, cardiologist at Mount Sinai Hospital in New York City, who was not involved in the study, told theheart.org | Medscape Cardiology.

"The average decrease in number of anginal attacks after 16 weeks of treatment was almost six attacks fewer in the group receiving acupuncture on the disease-affected meridian compared to the group receiving no acupuncture," Vaishnava observed.

The study was published online July 29 in JAMA Internal Medicine.

Plausible Mechanism?

Acupuncture on the disease-affected meridian causes autonomic remodeling by improving the balance between the vagus nerve and sympathetic nervous system during treatment, the researchers note in their article.

Previous work has suggested that acupuncture can ease symptoms of myocardial ischemia, improve cardiac function, and prevent recurrence. Several animal studies have validated the protective effect of acupuncture for cardiac ischemia and remodeling.

Results in angina to date are mixed. Some small studies have suggested a benefit of acupuncture in treating angina, whereas others have reported discrepancies concerning the efficacy of true versus sham acupuncture.

For this study, 404 adults with CSA, based on American College of Cardiology/American Heart Association criteria, with angina occurring at least twice weekly were enrolled at five centers in China. All participants were on guideline-based antianginal therapies but continued to have angina attacks.

In an equal ratio, they were randomly allocated to acupuncture in the disease-affected meridian, acupuncture in the nonaffected meridian, sham acupuncture, or no acupuncture.

Participants in the three acupuncture groups had treatment sessions three times weekly for 4 weeks, for a total of 12 sessions. Participants used diaries to record angina attacks. The primary outcome was the change in frequency of angina attacks every 4 weeks from baseline to week 16.

In an intention-to-treat analysis of 398 participants (253 women and 145 men; mean age, 62.6 years), mean changes in the frequency of angina attacks differed significantly among the four groups at 16 weeks.

Acupuncture on acupoints in the disease-affected meridian led to a significant reduction in the frequency of angina attacks, compared with acupoints in the nonaffected-meridian group (difference, 4.07; 95% CI, 2.43 - 5.71; P < .001) the sham group (difference, 5.18; 95% CI, 3.54 - 6.81; P < .001), and the wait-list group (difference, 5.63; 95% CI, 3.99 - 7.27; P < .001).

It also led to improvements in 6-minute walk distance, Canadian Cardiovascular Society angina grade, and most metrics of the Seattle Angina Questionnaire, and also resulted in better regulation of anxiety and depression in the 12 weeks after treatment than at the end of the treatment period.

More Study Needed

Acupuncture in the disease-affected meridian had "clinically relevant benefits" in reducing angina frequency and pain intensity, the study team writes.

They caution, however, that the study was limited by small study size and the fact that the patients were healthy at baseline. Also the durability of acupuncture is unknown.

Vaishnava agrees that more study is needed. The findings "should be replicated in a larger population, and the impact of acupuncture should be evaluated over a longer period of time," he told theheart.org | Medscape Cardiology.

"It would also be useful to establish the cost-effectiveness of acupuncture as an adjunctive antianginal strategy. Lastly, the impact of acupuncture should be studied in a 'sicker' population, as those in this study did not have a history of myocardial infarction," said Vaishnava.

Support for the study was provided by the National Nature Science Foundation of China and the State Key Program for Basic Research of China . The authors and Vaishnava have disclosed no relevant financial relationships.

JAMA Intern Med. Published online July 29, 2019. Full text

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