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
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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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