Abstract
In the last decades, various non-pharmacological solutions have been tested on top of medical therapy for the treatment of patients affected by refractory angina (RA). Among these therapeutics, neuromodulation, external counter-pulsation and coronary sinus constriction have been recently introduced in the guidelines for the management of RA in United States and Europe. Notably and paradoxically, although a consistent body of evidence has proposed cell-based therapies (CT) as safe and salutary for RA outcome, CT has not been conversely incorporated into current international guidelines yet. As a matter of fact, published randomized controlled trials (RCT) and meta-analyses (MTA) cumulatively indicated that CT can effectively increase perfusion, physical function and well-being, thus reducing angina symptoms and drug assumption in RA patients. In this review, we (i) provide an updated overview of novel non-pharmacological therapeutics included in current guidelines for the management of patients with RA, (ii) discuss the Level of Evidence stemmed from available clinical trials for each recommended treatment, and (iii) focus on evidence-based CT application for the management of RA.
Highlights
Refractory angina (RA) is a clinical condition defined by the presence of persistent (≥3 months) symptoms of angina, according to the Canadian Cardiovascular Society (CCS) class, which is caused by untreatable coronary artery disease with objective evidence of reversible myocardial ischemia [1, 2]
spinal cord stimulation (SCS) in this clinical context does not seem to be an attractive area of investigation anymore if we look at the number of ongoing registered studies on clinicaltrials.gov
After exhausting traditional medical therapies, the options for RA are very limited with external counterpulsation (EECP), SCS and coronary sinus reducer (CSR) being the only recommended approaches [2, 23]
Summary
Refractory angina (RA) is a clinical condition defined by the presence of persistent (≥3 months) symptoms of angina, according to the Canadian Cardiovascular Society (CCS) class, which is caused by untreatable coronary artery disease with objective evidence of reversible myocardial ischemia [1, 2]. The ESBY trial, in which 53 RA patients receiving SCS were compared with 51 controls receiving coronary artery bypass grafting (CABG) for symptomatic indication “only”, demonstrated an equivalent effect of both treatments in terms of angina relief at 6 months (p < 0.0001); the CABG group experienced higher exercise capacity and decreased ST-segment depression at follow-up [56].
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