Contemporary Management of Refractory Angina

Abstract

Refractory angina (RA) is defined as chest pain caused by coronary ischemia in patients on maximal medical therapy and is not amenable to revascularization despite advanced coronary artery disease (CAD). The long-term prognosis has improved with optimal medical therapy including risk factor modification. Still, patients are left with major impairment in quality of life and have high resource utilization with limited treatment options. We review the novel invasive and noninvasive therapies under investigation for RA.

Keywords: Angina; Coronary artery disease; Microvascular.

Figure 1.

(A) Microvascular angina with minimal CAD; Phenotype that reflects objective evidence of myocardial ischemia without significant coronary stenosis. (B) Limited territory at risk; Significant stenosis to cause angina but not amenable to PCI and not sufficiently severe to justify first/redo CABG. (C) Diffuse threadlike CAD; <1 mm distal runoffs of threadlike appearance from proximal to distal beds. (D) End-stage CAD; Coronaropenia combines proximal stenosis and diffuse atherosclerosis of distal beds. Generally seen in prior, degenerated CABG. Borrowed with permissions from Jolicoeur EM, Cartier R, Henry TD, et al. Patients With Coronary Artery Disease Unsuitable for Revascularization: Definition, General Principles, and a Classification. Can J Cardiol 2012;29(2 Suppl):S50-S59. Note that Phenotype A is now termed “Microvascular angina with minimal CAD.”

Figure 2.

Refractory Angina Treatments Borrowed with permissions from Gallone G, Baldetti L, Tzanis G, et al. Refractory Angina, From Pathophysiology to New Therapeutic Nonpharmacological Technologies. JACC Cardiovascl Interv 2020;13(1):1–19.