Abstract
BackgroundThe aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina.MethodsWe searched a number of electronic databases including Medline, Embase and Cochrane Library up to February 2008 to identify randomised controlled trials (RCTs) reporting exercise capacity, ischemic burden, functional class, quality of life, usage of anti-anginal medication, costs and adverse events including mortality. Results were reported both descriptively for each study and using random effects meta-analysis. Given the variety in outcomes reported, some outcome results were pooled as standardised mean differences (SMD) and reported in standard deviation units.ResultsSeven RCTs were identified in a total of 270 refractory angina patients. The outcomes of SCS were found to be similar when directly compared to coronary artery bypass grafting (CABG) and percutaneous myocardial laser revascularisation (PMR). Compared to a 'no stimulation' control, there was some evidence of improvement in all outcomes following SCS implantation with significant gains observed in pooled exercise capacity (SMD: 0.76, 0.07 to 1.46, p = 0.03) and health-related quality of life (SMD: 0.83, 95% CI: 0.32 to 1.34, p = 0.001). Trials were small and were judged to range considerably in their quality. The healthcare costs of SCS appeared to be lower than CABG at 2-years follow up.ConclusionSCS appears to be an effective and safe treatment option in the management of refractory angina patients and of similar efficacy and safety to PMR, a potential alternative treatment. Further high quality RCT and cost effectiveness evidence is needed before SCS can be accepted as a routine treatment for refractory angina.
Highlights
The aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina
The term 'refractory angina' is defined as "a chronic condition caused by clinically established reversible myocardial ischemia in the presence of coronary artery disease, which cannot be adequately controlled by a combination of medical therapy, angioplasty or coronary artery bypass operations" [1]
The randomised controlled trials (RCTs) of Lanza et al was excluded on grounds that it was based on patients with Syndrome X [30]
Summary
The aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina. The term 'refractory angina' is defined as "a chronic condition caused by clinically established reversible myocardial ischemia in the presence of coronary artery disease, which cannot be adequately controlled by a combination of medical therapy, angioplasty or coronary artery bypass operations" [1]. It is estimated that in Europe the incidence of refractory angina is 100.000 new cases per year [2] For this patient group, a number of non-conventional treatment options have emerged including, pharmacotherapy, enhanced external counterpulsation, percutaneous myocardial laser revascularisation (PMR), percutaneous coronary artery bypass (CABG), and spinal cord stimulation (SCS) [1,3]. SCS has been successfully used to relieve pain in a number of chronic conditions including neuropathic pain and peripheral vascular disease [5,6,7]
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