Chronic stable angina spinal cord stimulation
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Chronic stable angina spinal cord stimulation On the Web | ||
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to Hospitals Treating Chronic stable angina spinal cord stimulation | ||
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Risk calculators and risk factors for Chronic stable angina spinal cord stimulation | ||
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [4]; Associate Editor(s)-In-Chief: John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Spinal cord stimulation (SCS) uses an implanted device with an electrode tip that extends into the dorsal epidural space, usually at the C7-T1 level.
Mechanism of Benefit
- Spinal cord stimulation uses an implantable device with a atimulating electrode placed in the epidural space, usually at the level of C7-T1 and provides analgesia secondary to neuromodulation.
- SCS benefits secondary to:
- Decrease in the neurotransmission of painful stimuli,
- Increase in the release of endogenous opiates,
- Redistributes myocardial blood flow to ischemic areas.
Indication
In patients with chronic stable angina refractory to medical therapy, PCI, and/or surgical therapy (more data are still needed and therefore, spinal cord stimulation should be only considered when other treatment options have failed).
Supportive trial data
Several observational studies have reported success rates of up to 80% in decreasing anginal frequency and severity.
Randomized-Control Studies
- Efficacy of spinal cord stimulation as a treatment for chronic intractable angina, was studied in a small randomized-control study involving 13 patients treated with spinal cord stimulation versus 12 control patients with chronic angina. At 6-week follow-up, in comparison to the control group, the treated group demonstrated significant increase in the exercise duration (P=0.03) and the time to angina (P=0.01); and a significant reduction in the incidence of anginal attacks and sublingual nitrate consumption (P=0.01) and in the incidence of ischemic episodes on 48-hour electrocardiogram (P=0.04). The ST segment depression on the exercise electrocardiogram decreased at comparable workload (P=0.01) with a significant increase in the perceived quality of life (P=0.03). Thus, the study concluded that spinal cord stimulation is an effective alternative the management of chronic intractable angina pectoris, and that its effect was exerted through anti-ischemic action.[1]
- Another small study, involving 24 patients with refractory angina off which 12 patients were implanted with a spinal cord stimulator versus 12 in the control group. The efficacy in terms of recurrence of angina, nitroglycerin intake, ischemia, and heart rate variability using 48-hour electrocardiographic monitoring were assessed at 4-weeks and 8-weeks. In addition, neurohormonal status and symptom-limited aerobic capacity were also evaluated. The study reported no significant increase in the incidence of anginal complaints or ischemia after withholding stimulation. Neurohormonal levels and aerobic capacity were not altered. Thus, the study concluded that there was no adverse clinical rebound phenomenon after withholding neurostimulation in patients with refractory angina pectoris.[2]
Retrospective Studies
Three retrospective studies that assessed the efficacy of spinal cord stimulation in the management of refractory angina, reported an improvement observed with the chronic use of neurostimulation; however, the predictors of clinical outcomes were related to the traditional CAD risk factors and the mortality rate of patients with refractory angina treated with spinal cord stimulation was found to be similar to that of patients with chronic stable coronary artery disease.[3][4][5]
Prospective Study
One prospective study that evaluated the effect of spinal cord stimulation (SCS) on regional myocardial perfusion as assessed by positron emission tomography, reported a SCS-induced improvement in the exercise-induced angina and electrocardiographic signs of ischemia; however, this influence did not appear to be mediated by the changes in regional myocardial perfusion.[6]
Cohort Studies
Four cohort studies that evaluated the effect of spinal cord stimulation in the management of refractory angina, reported significant relief of anginal symptoms and an improvement in exercise tolerance secondary to the reduction in myocardial ischemia.[7][8][9] Thus, these studies concluded the use of SCS as an effective adjuvant therapy for intractable angina, despite a relatively disadvantage of frequent electrode dislocation.[10]
ACC/AHA Guidelines- Spinal Cord Stimulation (DO NOT EDIT)[11][12]
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Class IIb |
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Vote on and Suggest Revisions to the Current Guidelines
Sources
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [11]
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [12]
- Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [13]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [14]
References
- ↑ Hautvast RW, DeJongste MJ, Staal MJ, van Gilst WH, Lie KI (1998) Spinal cord stimulation in chronic intractable angina pectoris: a randomized, controlled efficacy study. Am Heart J 136 (6):1114-20. PMID: 9842028
- ↑ Jessurun GA, DeJongste MJ, Hautvast RW, Tio RA, Brouwer J, van Lelieveld S et al. (1999) Clinical follow-up after cessation of chronic electrical neuromodulation in patients with severe coronary artery disease: a prospective randomized controlled study on putative involvement of sympathetic activity. Pacing Clin Electrophysiol 22 (10):1432-9. PMID: 10588144
- ↑ TenVaarwerk IA, Jessurun GA, DeJongste MJ, Andersen C, Mannheimer C, Eliasson T et al. (1999) Clinical outcome of patients treated with spinal cord stimulation for therapeutically refractory angina pectoris. The Working Group on Neurocardiology. Heart 82 (1):82-8. PMID: 10377314
- ↑ Murray S, Carson KG, Ewings PD, Collins PD, James MA (1999) Spinal cord stimulation significantly decreases the need for acute hospital admission for chest pain in patients with refractory angina pectoris. Heart 82 (1):89-92. PMID: 10377316
- ↑ Jessurun GA, Ten Vaarwerk IA, DeJongste MJ, Tio RA, Staal MJ (1997) Sequelae of spinal cord stimulation for refractory angina pectoris. Reliability and safety profile of long-term clinical application. Coron Artery Dis 8 (1):33-8. PMID: 9101120
- ↑ De Landsheere C, Mannheimer C, Habets A, Guillaume M, Bourgeois I, Augustinsson LE et al. (1992) Effect of spinal cord stimulation on regional myocardial perfusion assessed by positron emission tomography. Am J Cardiol 69 (14):1143-9. PMID: 1575182
- ↑ Greco S, Auriti A, Fiume D, Gazzeri G, Gentilucci G, Antonini L et al. (1999) Spinal cord stimulation for the treatment of refractory angina pectoris: a two-year follow-up. Pacing Clin Electrophysiol 22 (1 Pt 1):26-32. PMID: 9990597
- ↑ Hautvast RW, Blanksma PK, DeJongste MJ, Pruim J, van der Wall EE, Vaalburg W et al. (1996) Effect of spinal cord stimulation on myocardial blood flow assessed by positron emission tomography in patients with refractory angina pectoris. Am J Cardiol 77 (7):462-7. PMID: 8629585
- ↑ Eliasson T, Albertsson P, Hårdhammar P, Emanuelsson H, Augustinsson LE, Mannheimer C (1993) Spinal cord stimulation in angina pectoris with normal coronary arteriograms. Coron Artery Dis 4 (9):819-27. PMID: 8287216
- ↑ de Jongste MJ, Nagelkerke D, Hooyschuur CM, Journée HL, Meyler PW, Staal MJ et al. (1994) Stimulation characteristics, complications, and efficacy of spinal cord stimulation systems in patients with refractory angina: a prospective feasibility study. Pacing Clin Electrophysiol 17 (11 Pt 1):1751-60. PMID: 7838783
- ↑ 11.0 11.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).Circulation 99 (21):2829-48. PMID: 10351980
- ↑ 12.0 12.1 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58. PMID: 12515758
- ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). [url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [1] "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology"] Check
|url=value (help). Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367. - ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[2] PMID: 17998462