From the Guidelines
Refractory angina treatment should prioritize enhanced external counterpulsation (EECP) therapy, as it has been shown to significantly reduce symptoms by improving coronary perfusion, according to the most recent guidelines 1. The treatment of refractory angina requires a comprehensive approach, considering various options to alleviate symptoms and improve quality of life.
Key Considerations
- EECP therapy, consisting of 35 one-hour sessions over 7 weeks, can be an effective treatment option for refractory angina, as recommended by the 2019 ESC guidelines 1.
- Spinal cord stimulation and a reducer device for coronary sinus constriction may also be considered for symptom relief, although the evidence is less robust compared to EECP therapy 1.
- Transmyocardial revascularization is not recommended due to the lack of evidence supporting its effectiveness in treating refractory angina 1.
Treatment Options
- EECP therapy: 35 one-hour sessions over 7 weeks, as recommended by the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update 1.
- Spinal cord stimulation: involving implantation of electrodes that deliver mild electrical impulses to block pain signals, as suggested by the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline 1.
- Novel therapies, such as ranolazine and ivabradine, may also be considered, although their effectiveness in refractory angina is less well-established.
Lifestyle Modifications
- Smoking cessation, regular moderate exercise within tolerance, weight management, and stress reduction techniques are crucial in managing refractory angina and improving overall quality of life. It is essential to weigh the potential benefits and risks of each treatment option and consider the individual patient's needs and preferences when developing a treatment plan for refractory angina.
From the FDA Drug Label
Ranolazine Extended-Release Tablets has been evaluated in patients with chronic angina who remained symptomatic despite treatment with the maximum dose of an antianginal agent In the ERICA (Efficacy of Ranolazine In Chronic Angina) trial, 565 patients were randomized to receive an initial dose of Ranolazine Extended-Release Tablets 500 mg twice daily or placebo for 1 week, followed by 6 weeks of treatment with Ranolazine Extended-Release Tablets 1000 mg twice daily or placebo, in addition to concomitant treatment with amlodipine 10 mg once daily Statistically significant decreases in angina attack frequency (p=0.028) and nitroglycerin use (p=0.014) were observed with Ranolazine Extended-Release Tablets compared to placebo.
Treatment options for refractory angina include:
- Ranolazine Extended-Release Tablets, which has been shown to decrease angina attack frequency and nitroglycerin use in patients with chronic angina who remained symptomatic despite treatment with the maximum dose of an antianginal agent 2
- The recommended dose is 1000 mg twice daily, in addition to concomitant treatment with other antianginal agents such as amlodipine 2
- Ranolazine Extended-Release Tablets has been evaluated in patients with chronic angina and has been shown to be effective in reducing angina symptoms 2
From the Research
Treatment Options for Refractory Angina
The treatment options for refractory angina can be categorized into pharmacological, non-invasive, and invasive therapies.
- Pharmacological treatment options include:
- Ranolazine, a new drug indicated for the treatment of chronic angina, in combination with amlodipine, beta-blockers or nitrates 3
- L-arginine, ivabradine, nicorandil, and trimetazidine, which are evolving pharmacological therapies for chronic refractory angina 4
- Testosterone, and estrogen, which are approved by the Food and Drug Administration for the treatment of refractory angina 5
- Non-invasive treatment options include:
- Enhanced external counterpulsation, which has been shown to improve symptoms and long-term ventricular function in patients with refractory angina 3, 6, 4, 5
- Transcutaneous electrical nerve stimulation, which has been used to treat refractory angina 6, 5
- Spinal cord stimulation, which has been shown to be effective in reducing angina symptoms 3, 6, 5
- Invasive treatment options include:
- Transmyocardial laser revascularization, which has emerged as an invasive treatment for refractory angina over the last two decades 3, 6, 4, 5
- Percutaneous transmyocardial laser revascularization, and percutaneous in situ coronary venous arterialization, which are still under investigation 3, 6
- Gene therapy, which is also being investigated as a potential treatment for refractory angina 3, 5
Novel Therapies
Novel therapies, such as therapeutic angiogenesis, are being developed to treat refractory angina 6.