Treatment Of Refractory Angina Research Articles

Enhanced external counterpulsation in cardiac rehabilitation in patients with coronary heart disease: a literature review

Enhanced external counterpulsation (EECP) is a non-invasive, outpatient, pulsatile-assisted circulation technique that has been used in many diseases, such as diabetes, stroke, and coronary heart disease (CHD). EECP can improve blood flow dynamics, vascular endothelial function, atherosclerosis outcomes, and other cardiovascular attributes through synchronous cardiac systolic and diastolic movements, thus playing a therapeutic role. EECP has been widely used in the treatment of refractory angina pectoris and plays a significant role in the treatment and rehabilitation of patients with CHD. As a passive aerobic exercise, it enables new ways for patients with cardiovascular disease who cannot carry out exercise rehabilitation to perform aerobic exercise. EECP will become increasingly important as the incidence of chronic disease increases and the rehabilitation discipline develops. With increasing attention being focused on EECP, the literature has grown rapidly. To help researchers gain a comprehensive understanding of this area, this review focuses on the progress made in applying EECP to CHD cardiac rehabilitation globally, including a brief history of EECP, the working principle of EECP, etc. This review will help researchers grasp the research outline and gaps in the literature regarding EECP and will provide a reference for them in future studies.

A budget impact model and a cost-utility analysis of reducer device (Neovasc) in patients with refractory angina.

Refractory angina (RA) is a chronic condition characterized by the presence of debilitating angina symptoms due to established reversible ischemia in the presence of obstructive coronary artery disease (CAD). Treatments for this condition have undergone major developments in recent decades; however, the treatment for RA remains a challenge for medicine. In this sense, the Coronary Sinus Reducer System (CSRS) stands as the last line of therapy for ineligible patients for revascularization with reversible ischemia. The purpose of this report is to evaluate the potential burden on the National Health Service (NHS) and measure the health effects in terms of both quantity (life years) and quality-of-life aspects related to the reducer. Two different economic evaluation models were developed as part of the analysis. The budget impact was developed to estimate the potential burden on the NHS from incremental uptake of the use of the reducer in the target population. The utility cost analysis compares and evaluates the quality of life and health resource use and costs between the two alternatives, based on the research of Gallone et al. A deterministic and probabilistic sensitivity analysis was carried out to characterize the uncertainty around the parameters of the model. In the budget impact analysis (BIA), the reducer is shown to be more expensive in the first 2 years of the model, due to the gradual uptake in the market and the cost of the device. Starting from the third year, assuming maintenance of effectiveness, there are savings in terms of resource absorption in direct healthcare costs arising from hospitalizations, emergency department accesses, coronarography, and visits avoided. The BIA and cost-effectiveness model show that the reducer device, despite an increase in resources absorbed in the first years of implementation and use, has the potential to result in increased quality of life in patients with RA. These costs are largely offset in the short term by the improved clinical outcomes achievable leading to savings from the third year onward in the BIA and a dominance ratio in the cost-utility analysis.

Refractory angina pectoris: a 20-year (2003-2022) bibliometric analysis.

The increasing number of patients with refractory angina pectoris, combined with the aging population and improved survival rates among coronary heart disease patients, presents a significant challenge in contemporary cardiovascular medicine. The treatment of refractory angina has been an ongoing area of exploration, yet a comprehensive analysis of the existing literature on this topic is currently lacking. Therefore, this study aims to provide the first bibliometric analysis of publications related to refractory angina. A systematic search was conducted in the Web of Science database to identify articles related to refractory angina published between 2003 and 2022. The inclusion criteria were limited to articles and reviews written in English. CiteSpace software was utilized to conduct a collaborative network analysis of countries/regions, institutions and authors, co-occurrence analysis of keywords, and co-citation analysis of authors and references. A total of 1,386 publications were identified, with an annual publication volume exhibiting fluctuation over time. American and European countries and institutions demonstrated a leading position in terms of research output. Henry TD emerged as the most prolific researcher in the field, while Mannheimer C received the highest number of citations. The primary research hotspot within this field focused on the treatment of refractory angina, with recent emphasis on emerging treatments such as stem cell therapy and the coronary sinus reducer. A significant number of clinical trials have been conducted, with a continuous focus on patient benefits, quality of life, and survival prognosis. Significant progress has been made in the field of refractory angina pectoris in recent years. Novel treatment methods, including spinal cord stimulation, enhanced external counterpulsation, stem cell therapy, and the coronary sinus reducer, hold promising therapeutic prospects. However, further high-quality evidence-based research is essential to support these emerging interventions. Additionally, the development of comprehensive evidence-based guidelines for refractory angina treatment is crucial. Such guidelines would provide clinicians with a framework to navigate the complexities of treatment choices and optimize patient care in this challenging condition.

The Coronary Sinus Reducer Stent for the Treatment of Refractory Angina Pectoris: From the Conception of Innovation to Clinical Application.

The Neovasc Coronary Sinus Reducer Stent (CSRS) was developed for the treatment of patients who continue to suffer from disabling symptoms despite optimal medical therapy. This patient population with refractory angina symptoms is expected to grow, since life expectancy of individuals with atherosclerotic coronary artery disease is increasing. In this paper, we discussed the development of a novel device the CSRS and the upside-down strategy to rebuild a retrograde coronary pressure that was attenuated by the atherosclerotic disease.

REABILITAÇÃO CARDÍACA BASEADA EM EXERCÍCIO NA ANGINA REFRATÁRIA: EXPERIÊNCIA UNICÊNTRICA

Refractory angina (RA) is a chronic clinical condition characterized by angina pectoris, which occurs as a result of myocardial ischemia, unresponsive to conventional medical treatment (i.e. control of cardiovascular risk factors and other clinical conditions, in addition to antianginal drugs), which is not eligible for coronary interventions. Patients with RA evolve with great functional limitation due to pain and consequent loss of quality of life, and their improvement is the focus of treatment. Exercise-based cardiac rehabilitation (CR) is an adjuvant therapy that effectively promotes secondary prevention in patients with coronary artery disease, but it is rarely prescribed for patients with refractory angina due to concerns about adverse events during exercise, related to triggering ischemia myocardial infarction at low thresholds. In this review, we address the experience obtained with the management of patients with RA in a reference center for the treatment of RA, especially related to exercise-based CR. Some peculiarities in the evaluation and prescription of training in patients with RA and their understanding are important to promote greater safety and efficacy of physical exercise in this population.

Percutaneous implantation of a blood flow reducer in coronary sinus – a modern method for the treatment of refractory angina pectoris

Percutaneous implantation of a blood flow reducer in coronary sinus – a modern method for the treatment of refractory angina pectoris

Summary of Zhang Hongxing's Experience in Treating Refractory Angina Pectoris with Traditional Chinese Medicine

As a famous traditional Chinese medicine (TCM) expert in Shandong province and a famous veteran TCM expert in Dezhou city, Zhang Hongxing has been engaged in cardiovascular clinical work for more than 30 years. He has unique experience in the treatment of refractory angina pectoris. This paper comprehensively explains from the aspects of etiology and pathogenesis. His treatment is mostly based on syndrome differentiation, combined with the basic pharmacology of modern Chinese medicine to formulate prescriptions and drugs, and at the same time values the use of insect drugs. We hereby attach the clinical records, hoping to provide reference for clinical workers, which is conducive to the inheritance and development of famous Chinese medical academic experience.

Non-pharmacological treatment of refractory angina: The coronary sinus reducer, the new kid on the block.

Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients' quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments.

The Use of the Seattle Angina Questionnaire in Patients Who Underwent Spinal Cord Stimulation for Refractory Angina Pectoris.

The Seattle Angina Questionnaire (SAQ) is a self-administered questionnaire used in cardiac patients to quantify angina based on five scales: physical limitation scale, anginal stability scale, anginal frequency scale, treatment satisfaction scale, and the disease perception scale. Here we report the use of the SAQ to assess angina symptoms in 18 patients who underwent spinal cord stimulation (SCS) for refractory angina pectoris (RAP) at the Mayo Clinic. Electronic health records were searched to find patients who underwent SCS for the treatment of RAP at a single institution from 2003 to 2018. Eligible patients were asked to participate in a phone survey that included the SAQ. Out of 13 patients who still had their implant, six (46%) had minimal physical limitations. Ten patients (76.9%) had favorable anginal frequency scores, defined as minimal or mild. Out of the five patients who had their device removed, one (20%) had minimal physical limitations and three (60%) had favorable anginal frequency scores. There was a high treatment satisfaction score for both those with their implant in place and those with the device removed. The SAQ is useful as a comprehensive measure specific to patients with RAP assessing function, pain, and satisfaction. The utilization of this tool pre- and post-operatively may provide additional information to analyze the effectiveness of SCS for RAP.

Management of refractory angina: an update.

Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.

Coronary Sinus Reducing Stent for the Treatment of Refractory Angina Pectoris: A Health Technology Assessment.

AimTo summarize the evidence on the clinical effectiveness and safety of coronary sinus reducing stent (CSRS) therapy in refractory angina pectoris (AP) patients.MethodsWe performed a systematic literature search in common databases (n=4). The evidence obtained was summarized according to GRADE methodology. A health technology assessment (HTA) was conducted using the HTA Core Model® for Rapid Relative Effectiveness Assessment. Primary outcomes for the clinical effectiveness domain were the proportion of patients with improvement in two or more Canadian Cardiovascular Society (CCS) angina score classes, overall mean reduction of CCS class, and Seattle Angina Questionnaire (SAQ) quality of life (QoL) score improvement. Outcomes for the safety domain were adverse device effects (ADEs) and serious adverse device effects (SADEs).ResultsOne randomized controlled trial (RCT) was identified. Outcomes that showed statistically significant differences between CSRS and sham treatment (in favor of CSRS) were CCS angina score improvement of one or two classes, overall mean reduction of CCS class, and SAQ QoL score improvement. Concerning safety, the sham-controlled trial data indicate that there were fewer SADEs in the intervention group (19%) than in the control group (46%). SADEs reported in observation studies ranged from none to 30%. The most frequently reported SADEs were death and stable angina. In the RCT, the only case of death occurred in the control group. Concerning clinical effectiveness, the risk of bias (RoB) was rated to be low, and concerning safety, the RoB was rated to range from low to moderate. As assessed by GRADE, the overall strength of evidence for effectiveness and safety was moderate. Internal and external validity of the evidence base were low.ConclusionEven though the current evidence indicates that the assessed technology, CSRS, is potentially more effective than sham intervention for refractory AP patients, the lack of internal validity of the studies undermines the partially positive results.

Non-pharmacological Treatment of Refractory Angina and Microvascular Angina.

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.

The Coronary Sinus Reducer - Clinical Evidence and New Perspectives On An Emerging Tool in the Treatment of Refractory Angina.

The coronary sinus reducer represents an emerging therapeutic option for patients suffering from chronic refractory angina. Current data indicate that the population suffering from angina symptoms despite maximal medical therapy and maximal achievable revascularisation - surgical or percutaneous - is constantly increasing. Also, the clinical outcome for these patients is strongly affected by the lack of adequate treatment, the occurrence of adverse events and the need for repeated hospitalisation. Growing evidence supports the clinical benefits of the coronary sinus reducer in relieving angina symptoms in this specific population, with emerging evidence of reduction in myocardial ischaemia following the implantation of the coronary sinus reducer. In this review, we provide an up-to-date description of the role of this relatively new device in the treatment of refractory angina, focusing not only on symptom relief but also on the increasing data that supports objective improvements in myocardial ischaemia.

Is there RCT evidence to support the use of transmyocardial laser revascularization compared with medical therapy for the treatment of refractory angina?

Is there RCT evidence to support the use of transmyocardial laser revascularization compared with medical therapy for the treatment of refractory angina?

Coronary sinus reduction for the treatment of refractory angina

A growing number of patients with severe and diffuse obstructive coronary artery disease who are not candidates for revascularisation have debilitating angina despite medical therapy.

Apheresis as novel treatment for refractory angina with raised lipoprotein(a): a randomized controlled cross-over trial

To determine the clinical impact of lipoprotein apheresis in patients with refractory angina and raised lipoprotein(a) > 500 mg/L on the primary end point of quantitative myocardial perfusion, as well as secondary end points including atheroma burden, exercise capacity, symptoms, and quality of life. We conducted a single-blinded randomized controlled trial in 20 patients with refractory angina and raised lipoprotein(a) > 500 mg/L, with 3 months of blinded weekly lipoprotein apheresis or sham, followed by crossover. The primary endpoint was change in quantitative myocardial perfusion reserve (MPR) assessed by cardiovascular magnetic resonance. Secondary endpoints included measures of atheroma burden, exercise capacity, symptoms and quality of life. The primary endpoint, namely MPR, increased following apheresis (0.47; 95% CI 0.31-0.63) compared with sham (-0.16; 95% CI - 0.33-0.02) yielding a net treatment increase of 0.63 (95% CI 0.37-0.89; P < 0.001 between groups). Improvements with apheresis compared with sham also occurred in atherosclerotic burden as assessed by total carotid wall volume (P < 0.001), exercise capacity by the 6 min walk test (P = 0.001), 4 of 5 domains of the Seattle angina questionnaire (all P < 0.02) and quality of life physical component summary by the short form 36 survey (P = 0.001). Lipoprotein apheresis may represent an effective novel treatment for patients with refractory angina and raised lipoprotein(a) improving myocardial perfusion, atheroma burden, exercise capacity and symptoms.

Angina and Its Management.

Angina pectoris is defined as substernal chest pain, pressure, or discomfort that is typically exacerbated by exertion and/or emotional stress, lasts greater than 30 to 60 seconds, and is relieved by rest and nitroglycerin. There are approximately 10 million people in the United States who have angina, and there are over 500 000 cases diagnosed per year. Several studies now show that angina itself is a predictor of major adverse cardiac events. In addition, angina is a serious morbidity that impedes quality of life and should be treated. In the United States, pharmacologic therapy for angina includes β-blockers, nitrates, calcium channel blockers, and the late sodium current blocker ranolazine. In other countries, additional pharmacologic agents include trimetazidine, ivabradine, nicorandil, fasudil, and others. Revascularization is indicated in certain high-risk individuals and also has been shown to improve angina. However, even after revascularization, a substantial percentage of patients return with recurrent or continued angina, requiring newer and better therapies. Treatment for refractory angina not amenable to usual pharmacologic therapies or revascularization procedures, includes enhanced external counterpulsation, transmyocardial revascularization, and stem cell therapy. Angina continues to be a significant cause of morbidity. Therapy should be geared not only to treating the risk factors for atherosclerotic disease and improving survival but should also be aimed at eliminating or reducing the occurrence of angina and improving the ability of patients to be active.

Spinal Cord Stimulation for Refractory Angina Pectoris: A Systematic Review and Meta-analysis.

Objectives:Paresthesia-free stimulation such as high frequency and burst have been demonstrated as effective therapies for neuropathic pain. The aim of this meta-analysis was to evaluate the efficacy and safety of conventional spinal cord stimulation (SCS) in the treatment of refractory angina pectoris (RAP).Materials and Methods:Relevant randomized controlled trials that investigated SCS for patients with RAP were comprehensively searched in Medline, Pubmed, Embase, and Cochrane Library. Five meta-analyses were performed examining the changes in Canadian Cardiovascular Society classes, exercise time, Visual Analog Scale (VAS) scores of pain, Seattle Angina Questionnaire, and nitroglycerin use in RAP patients after SCS therapy. We analyzed standardized mean differences (MD) and 95% confidence intervals (CIs) for each outcome by Review Manager 5.0 and STATA 12.0.Results:A total of 12 randomized controlled trials involving 476 RAP patients were identified. A trend of reduction in the angina frequency (MD=−9.03, 95% CI, −15.70 to −2.36) and nitroglycerin consumption (MD=−0.64, 95% CI, −0.84 to −0.45) could be observed in the SCS group. Compared with the control group, SCS showed benefit on increasing exercise time (MD=0.49, 95% CI, 0.13-0.85) and treatment satisfaction (MD=6.87, 95% CI, 2.07-11.66) with decreased VAS scores of pain (MD=−0.50, 95% CI, −0.81 to −0.20) and disease perception (MD=−8.34, 95% CI, −14.45 to −2.23). However, the result did not reach the significance level in terms of physical limitation (95% CI, −8.75 to 3.38; P=0.39) or angina stability (95% CI, −7.55 to 3.67; P=0.50).Discussion:The current meta-analysis suggested that SCS was a potential alternative in the treatment of PAP patients. Further investigation for finding the appropriate intensity of stimulation is required before this treatment should be widely recommended and applied.

Percutaneous Device to Narrow the Coronary Sinus: Shifting Paradigm in the Treatment of Refractory Angina? A Review of the Literature.

Refractory angina pectoris is defined as a chronic debilitating condition characterized by the presence of chronic anginal symptoms due to a severe obstructive and/or diffuse coronary artery disease that cannot be controlled by the combination of medical therapy and/or revascularization (percutaneous or surgical). In addition, the presence of myocardial ischemia as a cause of the symptoms must have been documented. The coronary sinus reducer (CSR) is a recently introduced percutaneous device to treat patients with severe anginal symptoms refractory to optimal medical therapy and not amenable to conventional revascularization. The purpose of this review is to describe the current evidence from available studies measuring the clinical effect of the CSR implantation on the health and well-being of patients with refractory angina.

Narrowing of the Coronary Sinus: A Device-Based Therapy for Persistent Angina Pectoris.

Alongside the remarkable advances in medical and invasive therapies for the treatment of ischemic heart disease, an increasing number of patients with advanced coronary artery disease unsuitable for revascularization continue to suffer from angina pectoris despite optimal medical therapy. Patients with chronic angina have poor quality of life and increased levels of anxiety and depression. A considerable number of innovative therapeutic modalities for the treatment of chronic angina have been investigated over the years; however, none of these therapeutic options has become a standard of care, and none are widely utilized. Current treatment options for refractory angina focus on medical therapy and secondary risk factor modification. Interventions to create increased pressure in the coronary sinus may alleviate myocardial ischemia by forcing redistribution of coronary blood flow from the less ischemic subepicardium to the more ischemic subendocardium, thus relieving symptoms of ischemia. Percutaneous, transvenous implantation of a balloon expandable, hourglass-shaped, stainless steel mesh in the coronary sinus to create a fixed focal narrowing and to increase backwards pressure, may serve as a new device-based therapy destined for the treatment of refractory angina pectoris.