REFRACTORY ANGINA : Definition, epidemiology, and management Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista “Molinette” Università di Torino Congresso Nazionale della Società Italiana di Cardiologia – Roma, 17 Dicembre 2007 (h )

What is refractory angina? -> Definition Does refractory angina really exist? -> Epidemiology Can I do anything about it? -> Management Learning goals

What is refractory angina? -> Definition Learning goals

Mechanism of angina pectoris DeJongste et al, Heart 2004 AUTONOMIC NERVOUS SYSTEM LIMBIC SYSTEM MECHANICAL AND CHEMICUAL STIMULI ?

Refractory angina: scope of the problem Abbate et al, Eur Heart J 2007 MICROVASCULAR DYSFUNCTION REFRACTORY ANGINA INCOMPLETE REVASCULARIZATION RECURRENT ANGINA

Recurrent angina: a true challenge Abbate et al, Eur Heart J 2007

(In)complete revascularization

Microvascular dysfunction Lanza, Heart 2007

Refractory angina: definitions ACC/AHA 2002 Guidelines Occurrence of chest pain due to myocardial ischemia in a patient with severe coronary artery disease who cannot be managed adequately by lifestyle adjustment or medical therapy and who are not candidates for revascularization (interventional or surgical) DeJongste et al, Heart

Refractory angina: definitions A chronic (>3 months) condition characterized by the presence of angina caused by coronary insufficiency in the presence of CAD which cannot be controlled by a combination of medical therapy, PTCA and CABG. The presence of reversible myocardial ischemia should be clinically established to be the cause of the symptoms. 3 Mannheimer et al, Eur Heart J 2002

Does refractory angina really exist? -> Epidemiology Learning goals

US burden of refractory angina Yang et al, MCP 2004

US burden of refractory angina Yang et al, MCP 2004

EU burden of refractory angina

EU burden of refractory angina Lenzen et al, EJCN 2006; Mannheimer et al, Eur Heart J 2002 Approximately 7% of people between 45 and 74 years suffer from angina pectoris. At least 14% of those in whom coronary revascularization is indicated are ineligible for it. Of all those with angina, 5-10% will develop refractory angina. This amounts to 30-50,000 persons/year.

Angina despite optimal therapy Boden et al, NEJM 2007

Angina despite optimal therapy Boden et al, NEJM 2007 † p<0.05 at 1 and 3 years, but not at 5 years; ¶ P<0.001 favoring PCI at all time points

Reasons for not performing PTCA/CABG DeJongste et al, Heart 2004

Typical patient features DeJongste et al, Heart 2004

Can I do anything about it? -> Management Learning goals

I’ve got this great new operation- I think it’ll help you Why don’t we ask him what he wants? How about angiogenesis? Thanks Doc (?) The doctor-centered approach VS The patient-centered approach

The patient-centered approach I.Level 1 A.Tell patients about procedure related morbidity and mortality and proceed II.Level 2 A.Inform patients of risks and benefits in dialogue and help them come to a decision III.Level 3 A.Don’t take symptoms for granted. What really is the problem?

The approach to the patient with refractory angina I.Pain history; is the chest pain angina? II.Assess red flags (unstable angina, prognostically important disease) III.Optimise anti-anginal therapy IV.Assess and address angina beliefs and fears V.Assess expectations in dialogue

Maximize drug therapy

The NORTHERN Trial of VEGF in refractory angina Stewart et al, TCT 2007

Referral to an experienced interventionist

Referral to an experienced cardiac surgeon

Still a role for PTCA/CABG: the MASS II Trial Hueb et al, Circ 2007

Newer treatments for refractory angina

Management of refractory angina: the Greater Manchester Experience Paravertebral block One-hour new patient appointment covering medical history, examination, education & distribution of patient information sheets psychology Individual psychology covering relaxation techniques, and cardiac health anxieties. Usually 4 – 6 sessions TENS machine TENS machine training from specialist nurses Follow up pain medical appointment to assess outcome of the first 2 treatment modalities. Assessment for stellate ganglion blockade Stellate ganglion block Medical review Implantable therapies: Spinal cord stimulation Intrathecal delivery systems Full angina pain management programme Cardiology review to exclude new disease Medical review Opioid analgesics TENS=Transcutaneous Electrical Nerve Stimulator

Promising role of spinal cord stimulation

Promising role of spinal cord stimulation

Take home messages

We must be ready to look for and listen to patients with refractory angina

Don’t be shy and truly maximize medical therapy

A comprehensive and individualized approach is likely more successful

A comprehensive and individualized approach is likely more successful DeJongste et al, Heart 2004

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