www.metcardio.org refractory angina : definition, epidemiology, and management giuseppe...

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REFRACTORY ANGINA : REFRACTORY ANGINA :

Definition, epidemiology, and Definition, epidemiology, and

managementmanagement

Giuseppe Biondi-ZoccaiGiuseppe Biondi-Zoccai

Ospedale S. Giovanni Battista “Molinette”

Università di Torino

Congresso Nazionale della Società Italiana di Cardiologia – Roma, 17 Dicembre 2007 (h 15.00-15.10)

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What is refractory angina?

-> Definition

Does refractory angina really exist?

->

Epidemiology

Can I do anything about it?

-> Management

Learning goalsLearning goals

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What is refractory angina?

-> Definition

Learning goalsLearning goals

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Mechanism of angina pectorisMechanism of angina pectoris

DeJongste et al, Heart 2004

AUTONOMIC

NERVOUS

SYSTEM

LIMBIC

SYSTEM

MECHANICAL AND

CHEMICUAL STIMULI

?

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Refractory angina: Refractory angina: scope of the problemscope of the problem

Abbate et al, Eur Heart J 2007

MICROVASCULAR

DYSFUNCTION REFRACTORY

ANGINA

INCOMPLETE

REVASCULARIZATION

RECURRENT

ANGINA

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Recurrent angina: a true challengeRecurrent angina: a true challenge

Abbate et al, Eur Heart J 2007

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(In)complete revascularization(In)complete revascularization

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Microvascular dysfunctionMicrovascular dysfunction

Lanza, Heart 2007

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Refractory angina: definitionsRefractory 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 2004

11

22

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Refractory angina: definitionsRefractory angina: definitionsA 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.

33

Mannheimer et al, Eur Heart J 2002

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Does refractory angina really exist?

->

Epidemiology

Learning goalsLearning goals

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US burden of refractory anginaUS burden of refractory angina

Yang et al, MCP 2004

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US burden of refractory anginaUS burden of refractory angina

Yang et al, MCP 2004

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EU burden of refractory anginaEU burden of refractory angina

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EU burden of refractory anginaEU 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.

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Angina despite optimal therapyAngina despite optimal therapy

Boden et al, NEJM 2007

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Angina despite optimal therapyAngina 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

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Reasons for not performing Reasons for not performing PTCA/CABGPTCA/CABG

DeJongste et al, Heart 2004

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Typical patient featuresTypical patient features

DeJongste et al, Heart 2004

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Can I do anything about it?

->

Management

Learning goalsLearning goals

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I’ve got this greatnew operation- I think it’ll help you

Why don’t we ask him what

he wants?

How about angiogenesis?

Thanks Doc (?)

The doctor-centered approachVS

The patient-centered approach

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The patient-centered approach

I. Level 1A. Tell patients about procedure

related morbidity and mortality and proceed

II. Level 2A. Inform patients of risks and

benefits in dialogue and help them come to a decision

III.Level 3A. Don’t take symptoms for

granted. What really is the problem?

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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

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Maximize drug therapyMaximize drug therapy

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The NORTHERN Trial of The NORTHERN Trial of VEGF in refractory anginaVEGF in refractory angina

Stewart et al, TCT 2007

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Referral to an experienced Referral to an experienced interventionistinterventionist

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Referral to an experienced Referral to an experienced cardiac surgeoncardiac surgeon

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Still a role for PTCA/CABG: Still a role for PTCA/CABG: the MASS II Trialthe MASS II Trial

Hueb et al, Circ 2007

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Newer treatments for Newer treatments for refractory anginarefractory angina

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Management of refractory angina: the Greater Manchester Experience

Paravertebral blockParavertebral block

One-hour new patient appointment covering

medical history, examination, education &

distribution of patient information sheets

Individual psychologypsychology covering relaxation techniques, and

cardiac health anxieties. Usually 4 – 6 sessions

TENS machineTENS 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 blockStellate ganglion block

Medical review

Implantable therapies:Spinal cord stimulation Spinal cord stimulation

Intrathecal delivery systemsIntrathecal delivery systemsFull angina pain management programme

Cardiology review to exclude new disease

Medical review

Opioid analgesics

TENS=Transcutaneous Electrical Nerve Stimulator

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Promising role of spinal Promising role of spinal cord stimulationcord stimulation

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Promising role of spinal Promising role of spinal cord stimulationcord stimulation

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Take home messages

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

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Don’t be shy and truly maximize medical therapy

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A comprehensive and individualized approach is likely more successful

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A comprehensive and individualized approach is likely more successful

DeJongste et al, Heart 2004

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