Treatment options for refractory angina in patients who are not candidates for revascularization

Enhanced external counterpulsation for chronic angina pectoris

BACKGROUND

Cardiovascular disease is a major cause of death in developed and developing countries. Refractory stable angina pectoris is, in general, inadequately responsive to conventional medical therapy.Enhanced external counterpulsation is a non-invasive treatment for patients with refractory angina and involves the placing of compressible cuffs around the calves and lower and upper thighs. These are inflated sequentially so that during early diastole they help propel blood back to the heart and when deflated at end of diastole allow the blood vessels to return to their normal state. It is claimed that enhanced external counterpulsation can help reduce aortic impedance and thereby alleviate some of the symptoms of angina.

OBJECTIVES

To assess the effects of enhanced external counterpulsation therapy in improving health outcomes for patients with chronic stable or refractory stable angina pectoris.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2008, Issue 1), MEDLINE (1966 to February 2008), EMBASE (1980 to February 2008), LILACS via BIREME (to February 2008) and ISI Science Citation Index on Web of Science (to February 2008). No language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials and cluster-randomized trials comparing enhanced external counterpulsation therapy to sham treatment in adults, aged over 18 years, with chronic stable and stable refractory angina pectoris graded Canadian Cardiovascular Society Class III to IV at baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently screened papers, extracted trial details and assessed risk of bias.

MAIN RESULTS

One trial (139 participants) was included in this review. Poor methodological quality, in terms of trial design and conduct, incompleteness in reporting of the review's primary outcome, limited follow up for the secondary outcomes and subsequent flawed statistical analysis, compromised the reliability of the reported data.

AUTHORS' CONCLUSIONS

We found one relevant trial which failed to address the characteristics of interest satisfactorily, in terms of severity of angina, for the participants in this review. Participants with the most severe symptoms of angina were excluded, therefore the results of this study represent only a subsection of the broader population with the disorder, are not generalizable and provide inconclusive evidence for the effectiveness of enhanced external counterpulsation therapy for chronic angina pectoris.

Percutaneous coronary revascularization in patients with formerly "refractory angina pectoris in end-stage coronary artery disease" - not "end-stage" after all

Background

Patients with refractory angina pectoris in end-stage coronary artery disease represent a severe condition with a higher reduction of life-expectancy and quality of life as compared to patients with stable coronary artery disease. It was the purpose of this study to invasively re-evaluate highly symptomatic patients with formerly diagnosed refractory angina pectoris in end-stage coronary artery disease for feasible options of myocardial revascularization.

Methods

Thirty-four Patients formerly characterized as having end stage coronary artery disease with refractory angina pectoris were retrospectively followed for coronary interventions.

Results

Of those 34 patients 21 (61.8%) were eventually revascularized with percutaneous interventional revascularization (PCI). Due to complex coronary morphology (angulation, chronic total occlusion) PCI demanded an above-average amount of time (66 ± 42 minutes, range 25–206 minutes) and materials (contrast media 247 ± 209 ml, range 50–750 ml; PCI guiding wires 2.0 ± 1.4, range 1–6 wires). Of PCI patients 7 (33.3%) showed a new lesion as a sign of progression of atherosclerosis. Clinical success rate with a reduction to angina class II or lower was 71.4% at 30 days. Surgery was performed in a total of8 (23.5%) patients with a clinical success rate of 62.5%. Based on an intention-to-treat 2 patients of originally 8 (25%) demonstrated clinical success. Mortality during follow-up (1–18 months) was 4.8% in patients who underwent PCI, 25% in patients treated surgically and 25% in those only treated medically.

Conclusion

The majority of patients with end-stage coronary artery disease can be treated effectively with conventional invasive treatment modalities. Therefore even though it is challenging and demanding PCI should be considered as a first choice before experimental interventions are considered.