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J Am Coll Cardiol, 2002; 39:923-934
© 2002 by the American College of Cardiology Foundation
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REVIEW ARTICLE

Refractory angina pectoris

Mechanism and therapeutic options

Michael C. Kim, MDa, Annapoorna Kini, MDa and Samin K. Sharma, MD, FACCa,*

a Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York, USA

Manuscript received October 11, 2001; revised manuscript received December 26, 2001, accepted January 2, 2002.

* Reprint requests and correspondence: Dr. Samin K. Sharma, Mount Sinai Medical Center, P.O. Box 1030, One Gustave L. Levy Place, New York, New York 10029, USA.
samin.sharma{at}msnyuhealth.org

As the survival of patients with primary coronary events continues to increase, the number of patients presenting with coronary artery disease unsuitable to further revascularization techniques and symptoms refractory to medical therapy also continues to rise. The aims of this review were to define the population of patients with refractory angina pectoris and to present the therapeutic options currently available for this condition. Refractory angina pectoris is defined, and traditional medical therapies are discussed. Then, current therapeutic options for patients with refractory angina are extensively reviewed. A multitude of therapeutic options exist for patients with refractory angina pectoris. Small, uncontrolled studies have shown a potential benefit for additional antiplatelet and antithrombotic therapy. In randomized trials, neurostimulation has been shown to be effective in reducing angina symptoms. Enhanced external counterpulsation is a viable treatment option for select patients with refractory angina. In many randomized trials, laser revascularization has been shown to diminish angina symptoms, although no placebo-controlled studies exist to date. Gene therapy is a promising area of research in this field. Percutaneous in situ coronary venous arterialization is in its infancy, but may be able to treat many patients if proved successful. No data support the role of chelation therapy in this population. Heart transplantation remains a final option for these patients. Further research of the techniques mentioned in this review is warranted. The importance of randomized, double-blinded, placebo-controlled trials cannot be overemphasized, as the placebo effect of these therapies is probably marked.

Abbreviations and Acronyms
  PTMLR
  ACE
  angiotensin-converting enzyme
  bFGF
  basic fibroblast growth factor
  CABG
  coronary artery bypass graft surgery
  CAD
  coronary artery disease
  CCS
  Canadian Cardiovascular Society
  EDTA
  ethylenediamine-tetraacetic acid
  EECP
  enhanced external counterpulsation
  EMM
  electromechanical mapping
  LAD
  left anterior descending coronary artery
  LDL
  low-density lipoprotein
  LMWH
  low-molecular-weight heparin
  PCI
  percutaneous coronary intervention
  PICAB
  percutaneous in situ coronary venous arterialization
  PICVA
  percutaneous in situ coronary venous arterialization
  PTMLR
  percutaneous transmyocardial laser revascularization
  rFGF
  recombinant fibroblast growth factor
  SCS
  spinal cord stimulation
  SPECT
  single-photon emission computed tomography
  TENS
  transcutaneous electrical nerve stimulation
  TMLR
  transmyocardial laser revascularization
  VEGF
  vascular-endothelial growth factor




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