Treatment of chronic refractory angina pectoris—light at the end of the tunnel?The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

Abstract

Despite increasing number of coronary interventions over recent years, there is still a considerable number of patients suffering from chronic refractory angina pectoris. The volume of no option patients is not exactly known, but has been suggested to be 30 per million inhabitants per year; other estimates are 2.5–5% of coronary angiography procedures.1,2 The group of no option patients includes those who have angina despite optimal medical therapy; they may not have been offered PCI or CABG because of severe diffuse coronary artery disease, or they who continue to experience severe angina after CABG, PCI, or both. A considerable number of therapeutic strategies have been investigated to treat severe chronic angina, such as transcutaneous electric nerve stimulation (TENS), left stellate ganglion blockade (LSGB), endoscopic thoracoscopic symathectomy (ETS), thoracic epidural anaesthesia (TEDA), external balloon counter pulsation (EECP), stem cell therapy, and finally myocardial laser revascularization by surgical (TMR) or percutaneous (PMR) technique or spinal cord stimulation (SCS).1 These interventions have been suggested to have primary effect on pain; there is no valid evidence that any of these procedures reduces any clinical major cardiac endpoints. Only a few of these options have undergone the test of randomized studies, so the impact of a placebo effect on pain is largely not known. When trying to orientate in the jungle of mechanical or implant options to decide on how to advice patients, it may be helpful to look at the natural course of chronic refractory angina. We know that this group of patients often are in agony with severe coronary artery disease. It is therefore natural to first look at the data on mortality with drug therapy only. The suggestion of a mortality over 1-year of up to 17%2 is often quoted, however, there is other evidence suggesting that … *Corresponding author. Tel: +47 55972172; fax: +47 55975150. E-mail address : jan.nordrehaug{at}helse-bergen.no