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REVIEW ARTICLE

Refractory angina pectoris

Mechanism and therapeutic options

^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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