Case of the Month #19: Refractory Angina by Dr Sonia Pierce

Refractory angina refers to long-lasting symptoms (for >_3 months) due to established reversible ischaemia in the presence of obstructive coronary artery disease (CAD), which cannot be controlled by escalating medical therapy with the use of second- and third-line pharmacological agents, bypass grafting, or stenting including PCI of chronic total coronary occlusion2. Incidence is growing with more advanced CAD, multiple comorbidities, and ageing of the population. The quality of life of patients with refractory angina is poor, with frequent hospitalisation and a high level of resource utilisation2.

Refractory angina has profound effects on the quality of life of affected patients, limiting their mobility and professional or leisure activities3. It is often difficult to determine which patient’s pain relates to reversible myocardial ischaemia and which is confounded by underlying anxiety related to the knowledge of their often severe atherosclerotic CAD3. There is poor correlation between angina symptoms and coronary artery disease or ischaemia heart disease; silent ischaemia investigations in the ambulatory monitoring era inform us that 66% of ‘angina’ does not have evidence of myocardial ischaemia, while 85% of ambulatory ischaemia is symptomatically ‘silent’, and decades of research has shown that angina can occur in those with or without significant obstructive CAD, and angina also persists in many patients post-PCI4. The holistic approach of the pain service was helpful for the patient in this case report, but we should be aware that many options are available that are suitable for some patients but not others. A personalised approach should be used in the management of refractory angina, providing advice on approaches to limiting the impact of angina on daily life and lifestyle advice.

This open access review article gives a thorough, up to date review of the management of refractory angina3: Davies A, Fox K, Galassi AR, Banai S, Ylä-Herttuala S, Lüscher TF. Management of refractory angina: an update. Eur Heart J. 2021 Jan 20;42(3):269-283. The review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. Also covered are the symptomatic and prognostic impact of advanced and novel revascularisation strategies such as chronic total occlusion PCI, transmyocardial laser revascularisation, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation. In addition, the recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes are discussed.

This paper includes a review of the use of Spinal cord stimulation (SCS) for refractory angina. The review describes several studies that have reported beneficial effects on angina symptoms, quality of life and hospital re-admissions for angina. SCS has been found to have similar effects as CABG regarding symptoms and quality of life at the 6-month and the 5-year follow-ups, with long-term survival being 75.5% and 68.6% in SCS and in CABG patients, respectively. We recommend you read the review article for further details. 

We would also like to signpost you to the following review article, which describes the current and future perspectives on nonpharmacological treatment for patients with refractory angina5: Gallone G, Baldetti L, Tzanis G, Gramegna M, Latib A, Colombo A, Henry TD, Giannini F. Refractory Angina: From Pathophysiology to New Therapeutic Nonpharmacological Technologies. JACC Cardiovasc Interv. 2020 Jan 13;13(1):1-19. It concisely describes the pathways linking ischemia to symptom perception in a complex model of heart-brain interactions and the generation of the subjective anginal experience. It also covers a review of the novel approaches that may be clinically effective in alleviating the angina burden of this population. The authors review the current and the future nonpharmacological treatment technologies for patients with refractory angina and is worth a read. 

1)    https://www.bhf.org.uk/informationsupport/publications/large-print/angina---large-print

2)    Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41: 407–477.

3)    Davies A, Fox K, Galassi AR, Banai S, Ylä-Herttuala S, Lüscher TF. Management of refractory angina: an update. Eur Heart J. 2021 Jan 20;42(3):269-283.

4)    Mehta PK, Bess C, Elias-Smale S, Vaccarino V, Quyyumi A, Pepine CJ, Bairey Merz CN. Gender in cardiovascular medicine: chest pain and coronary artery disease. Eur Heart J. 2019 Dec 14;40(47):3819-3826.

5)    Gallone G, Baldetti L, Tzanis G, Gramegna M, Latib A, Colombo A, Henry TD, Giannini F. Refractory Angina: From Pathophysiology to New Therapeutic Nonpharmacological Technologies. JACC Cardiovasc Interv. 2020 Jan 13;13(1):1-19.