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Review
. 2022 Dec 22;3(1):oeac083.
doi: 10.1093/ehjopen/oeac083. eCollection 2023 Jan.

Neuromodulation in patients with refractory angina pectoris: a review

Fabienne Elvira Vervaat  1 , Antal van der Gaag  2 , Koen Teeuwen  1 , Hans van Suijlekom  2 , Inge Wijnbergen  1
Affiliations
Review

Neuromodulation in patients with refractory angina pectoris: a review

Fabienne Elvira Vervaat et al. Eur Heart J Open. .

Abstract

The number of patients with coronary artery disease (CAD) who have persisting angina pectoris despite optimal medical treatment known as refractory angina pectoris (RAP) is growing. Current estimates indicate that 5-10% of patients with stable CAD have RAP. In absolute numbers, there are 50 000-100 000 new cases of RAP each year in the USA and 30 000-50 000 new cases each year in Europe. The term RAP was formulated in 2002. RAP is defined as a chronic disease (more than 3 months) characterized by diffuse CAD in the presence of proven ischaemia which is not amendable to a combination of medical therapy, angioplasty, or coronary bypass surgery. There are currently few treatment options for patients with RAP. One such last-resort treatment option is spinal cord stimulation (SCS) with a Class of recommendation IIB, level of evidence B in the 2019 European Society of Cardiology guidelines for the diagnosis and management of chronic coronary syndromes. The aim of this review is to give an overview of neuromodulation as treatment modality for patients with RAP. A comprehensive overview is given on the history, proposed mechanism of action, safety, efficacy, and current use of SCS.

Keywords: Coronary artery disease; Refractory angina pectoris; Spinal cord stimulation.

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Conflict of interest statement

Conflict of interest: No conflict of interest to declare.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Current treatment options for refractory angina pectoris with class of recommendation and level of evidence in accordance with the 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. TENS, transcutaneous electrical nerve stimulation; SENS, subcutaneous electrical nerve stimulation.
Figure 2
Figure 2
Overview of the different forms of neuromodulation.
Figure 3
Figure 3
‘Open’ and ‘closed’ gate in accordance with the gate control theory of pain by Melzack and Wall.
Figure 4
Figure 4
Schematic overview of the neuro-humoral interaction between the heart and the central nervous system. A, neuro-humoral interaction from the heart to the central nervous system. B, Neuro-humoral interaction from the central nervous system to the heart.
Figure 5
Figure 5
Schematic overview of referred pain in myocardial ischaemia.
Figure 6
Figure 6
Schematic overview of the mechanisms of action of neuromodulation in patients with refractory angina pectoris. CBF, cerebral blood flow; MBF, myocardial blood flow; MPR, myocardial perfusion reserve; STT, spinothalamic tract.
Figure 7
Figure 7
Schematic overview of the screening process for spinal cord stimulation. AP, angina pectoris; CCS, Canadian Cardiovascular Society; Ca-channel, calcium-channel; CMR, cardiac magnetic resonance imaging; FFR, fractional flow reserve; LAN, long-acting nitrates; LCA, left coronary artery; MIBI, myocardial perfusion imaging; PET, positron emission tomography; RCA, right coronary artery; SCS, spinal cord stimulation; TENS, transcutaneous electrical nerve stimulation; TTE, transthoracic echocardiography.
Figure 8
Figure 8
Schematic overview of set-up spinal cord stimulator implantation.
See this image and copyright information in PMC

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