Guidelines on the Management of Stable Angina Pectoris ... - Cardio

46 ESC <strong>Guidelines</strong>was addressed in a Report from the ESC Joint Study Group onthe Treatment of Refractory Angina, published in 2002. 660Chronic stable refractory angina can be defined as a clinicaldiagnosis based on the presence of symptoms of stableangina, thought to be caused by ischaemia due to advancedcoronary disease and which are not controllable by a combinationof maximal medical therapy, bypass surgery and percutaneousintervention. Non-cardiac causes of chest painshould be excluded, and where appropriate, cognitive behaviouraltherapy, psychological assessment, and/or psychiatricconsultation may be considered.According to the previously mentioned report from theJoint Study Group, we have no accurate figures on theoccurrence and frequency of refractory angina. A Swedishsurvey of patients referred for coronary arteriographybecause of stable angina pectoris performed in 1994–95showed that nearly 10% of patients were rejected for revascularizationdespite severe symptoms. 661,662The most common reasons that revascularization is notconsidered appropriate are:(1) Unsuitable anatomy(2) One or several previous bypass grafting and/or PTCAprocedures(3) Lack of available graft conduits(4) Extra-cardiac diseases which increase perioperativemorbidity and mortality(5) Advanced age, often in combination with these factorsChronic refractory angina requires an effective optimizationof medical treatment assuring the use of differentdrugs in maximal tolerated doses. This issue is extensivelydeveloped in the original document of the Joint StudyGroup. Within the last few years, new modalities exploringnew concepts of therapy are under extensive evaluation,although not all have been successful: neuromodulationtechniques (transcutaneous electric nerve stimulation andspinal cord stimulation), thoracic epidural anaesthesia,endoscopic thoracic sympathectomy, stellate ganglionblockade, transmyocardial or percutaneous laser revascularization,angiogenesis, enhanced external counterpulsation,heart transplantation, and drugs that modulate metabolism.Transcutaneous electrical stimulation and spinal cordstimulation are well-established methods used in severalcentres for the management of refractory angina with positiveeffects on symptoms and a favourable side-effectprofile. 663–665 These techniques have a favourable analgesiceffect even without any improvement in myocardial ischaemia.A significant increase in the average exercise time ontreadmill testing has however been observed. The numberof published reports and the number of patients enrolledin clinical trials are small, and the long-term effects ofthese techniques are unknown.Enhanced external counterpulsation (EECP) is an interestingnon-pharmacological technique, which has also beeninvestigated largely in the USA. Two multi-centre registrieshave evaluated the safety and effectiveness of EECP. 666–668The technique is very well tolerated when used over aperiod of 35 hours of active counterpulsation during4–7-week period. Anginal symptoms were improved in75–80% of patients.Transmyocardial revascularization has been comparedwith medical therapy in several studies. In one study (in275 patients with CCS class IV symptoms), 76% of patientswho had undergone transmyocardial revascularizationimproved two or more functional classes after 1 year offollow-up, as compared with 32% (P , 0.001) of the patientswho received medical therapy alone. 669 Mortality did notdiffer significantly between the two groups. Other studiesof transmyocardial revascularization (either surgically or percutaneously)have been unable to confirm this benefit. 670,671In particular, a recent randomized controlled trial of 298patients showed that treatment with percutaneous myocardiallaser provides no benefit beyond that of a similar shamprocedure in patients blinded to their treatment. 672Furthermore, measurement of regional myocardial bloodflow and coronary flow reserve by means of PET has failedto show imporved perfusion following this procedure. 673International studies and registries are urgently requiredto clarify the epidemiology of this condition and furtherresearch is encouraged to definitely establish the roles ofexisting and novel alternative techniques to manage thesepatients.Conclusions and Recommendations(1) Angina pectoris due to coronary atherosclerosis is acommon and disabling disorder. Although compatiblewith longevity, there is an increased risk of progressionto MI and/or death. With proper management, thesymptoms can usually be controlled and the prognosissubstantially improved.(2) Every patient with suspected stable angina requiresprompt and appropriate cardiological investigation toensure that the diagnosis is correct and that the prognosisis evaluated. As a minimum, each patient shouldhave a carefully taken history and physical examination,a comprehensive risk factor evaluation, and aresting ECG.(3) To confirm the diagnosis and plan further management,an initial non-invasive strategy, using exercise ECG,stress echo, or myocardial perfusion scintigraphy ismost appropriate. This allows an assessment of thelikelihood of and the severity of CHD in patients withmild-to-moderate symptoms and effective risk stratification.In many patients, coronary arteriography mayfollow, but an initial invasive strategy without priorfunctional testing is rarely indicated, and may onlybe considered for patients with new onset severe oruncontrolled symptoms.(4) The exercise ECG should be interpreted with attentionto haemodynamic response, workload achieved, andclinical features of the individual as well as symptomsand ST-segment response. Alternative investigationsare needed when exercise is not possible or the ECG isnot interpretable, or in addition to exercise testingwhen the diagnosis remains uncertain or functionalassessment is inadequate.(5) In addition to their role in intial assessment of stableangina symptoms, myocardial perfusion scintigraphyand stress echocardiography are of particular value indemonstrating the extent and localization of myocardialischaemia.(6) Echocardiography and other non-invasive imaging modalities,such as magnetic resonance, are helpful in evaluatingventricular function.