Abstract
Refractory angina (RA) is defined as debilitating anginal symptoms despite the optimal guideline-directed combination of medical, percutaneous, and surgical therapies. Often referred to as “no option”, these patients represent a significant unmet clinical need for healthcare institutions. Due to the ageing of the population, and increased survival from coronary artery disease, the number of patients with RA is expected to rise exponentially. Despite the developments of novel technologies for the treatment of RA, none of them found wide clinical application (to date). Microvascular dysfunction, alone or in combination with epicardial coronary disease, is thought to contribute significantly to refractory angina. However, most of the techniques developed to improve RA symptoms have not been tested specifically on patients with microvascular dysfunction. This review discusses the recent developments in the treatment of RA, and gives some perspectives on the future of these techniques.
Highlights
The expression refractory angina (RA) refers to the presence of angina symptoms, usually for≥3 months which cannot be controlled by means of established pharmacological therapy, coronary bypass grafting or percutaneous interventions, including chronic total occlusions [1,2] the presence coronary artery disease (CAD), intended as obstructions of epicardial coronaries, is usually considered a prerequisite, RA may follow a wide range of clinical entities, including obstructive CAD, a microvascular disease with patent epicardial coronary arteries, hypertrophic cardiomyopathy, and left ventricular diastolic dysfunction [3]
The presence coronary artery disease (CAD), intended as obstructions of epicardial coronaries, is usually considered a prerequisite, RA may follow a wide range of clinical entities, including obstructive CAD, a microvascular disease with patent epicardial coronary arteries, hypertrophic cardiomyopathy, and left ventricular diastolic dysfunction [3]
Extracorporeal shockwave myocardial revascularization (ESMR) is another promising non-invasive technique aimed at improving myocardial perfusion in ischemic areas through the application of acoustic waves [12]
Summary
The expression refractory angina (RA) refers to the presence of angina symptoms, usually for. Data from several epidemiological studies report that 5% to 10% (7.7% women, 7.3% men) of the patients with stable CAD undergoing cardiac catheterization have refractory angina, and the annual incidence of RA in Europe estimated to be 30,000–50,000 and 75,000 in the United States [4]. This data might be unreliable and outdated for several reasons: Firstly, many studies did not include patients with no epicardial obstructive CAD and microvascular angina. TMLR, transmyocardial laser revascularization; RCT, randomized-controlled trial; ESC, European Society of Cardiology; ACC/AHA, American Society of Cardiology/American Heart Foundation; CABG, coronary artery bypass graft
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