Influence of socioeconomic status on survival after primary aortic or mitral valve replacement.

OBJECTIVES: We sought to evaluate whether socioeconomic status influences outcome after first-time single aortic or mitral valve replacement. SETTING: National Heart Valve registry. DESIGN AND PATIENTS: Between 1 January 1986 and 31 December 2001, 51 844 consecutive patients who underwent primary aortic or mitral valve replacement were registered on the United Kingdom (UK) Heart Valve Registry. Data included age, gender, valve position, type of valve implant, postcode, follow-up time, date and cause of death. The Carstairs deprivation score (1991 Census data for the UK) was used to stratify cases by level of social deprivation according to postcodes. RESULTS: Both 30-day and 1-year survival/mortality rates were similar across all socioeconomic levels. However, long-term survival rate (up to 15 years) was significantly higher in the least deprived socioeconomic level than in the two most deprived levels. There was an 18% lower survival rate amongst women in the most deprived levels (35.9%, 95% CI: 32.4 to 39.4) versus the least deprived level (43.7%, 95% CI: 38.1 to 49.2, p<0.004). In men, survival in the most deprived levels (39.5%, 95% CI: 36.4 to 42.5) was 7% lower than in the least deprived level (42.7%, 95% CI: 37.7 to 47.7, p<0.005). Biological valve, mitral position, female gender, and low socioeconomic status were all associated with long-term mortality. CONCLUSIONS: A disadvantaged social background has a negative influence on long-term survival after aortic or mitral valve replacement, especially among women.

The Coronary Artery Revascularisation in Diabetes (CARDia) trial: background, aims, and design.

BACKGROUND: Patients with diabetes have an increased incidence and severity of ischemic heart disease, which leads to an increased requirement for coronary revascularization. Comparative information regarding mode of revascularization--coronary artery bypass graft surgery surgery (CABG) or percutaneous coronary intervention (PCI)--is limited, mainly confined to a subanalysis of the Bypass Angioplasty Revascularization (BARI) trial, suggesting a mortality benefit of CABG over PCI. No prospective trial has specifically compared these modes of revascularization in patients with diabetes. OBJECTIVE: The Coronary Artery Revascularisation in Diabetes (CARDia) trial is designed to address the hypothesis that optimal PCI is not inferior to modern CABG as a revascularization strategy for diabetics with multivessel or complex single-vessel coronary disease. The primary end point is a composite of death, nonfatal myocardial infarction, and cerebrovascular accident at 1 year. METHOD: A total of 600 patients with diabetes are to be randomized to either PCI or CABG, with few protocol restrictions on operative techniques or use of new technology. This gives a power of 80% to detect non-inferiority of PCI assuming that the PCI 1-year event rate is 9%. A cardiac surgeon and a cardiologist must agree that a patient is suitable for revascularization by either technique prior to recruitment into the study. Twenty-one centers in the United Kingdom and Ireland are recruiting patients. Data on cost effectiveness, quality of life, and neurocognitive function are being collected. Long-term (3-5 year) follow-up data will also be collected.

A prospective study of long term prognosis in young myocardial infarction survivors: the prognostic value of angiography and exercise testing.

OBJECTIVES: To define the ability of early exercise testing and coronary angiography to predict prognosis in young survivors of myocardial infarction (MI). METHODS: 255 consecutive patients (210 men) aged 55 years or less (mean 48 years) admitted to hospital (1981-85) were eligible. Of these, 150 patients (130 men) who were able to exercise early after MI and underwent coronary angiography within six months constituted the study group and were followed up for up to 15 years. Survival data up to 18 years was obtained for the whole cohort. RESULTS: Survival at a median of 16 years was 52% for the whole cohort, 62% for the study group, and 48% for the excluded group. From nine years onwards survival deteriorated significantly in the study group compared with an age matched background population. Fifteen years after MI, 121 patients (81%) in the study group had had at least one event (death, MI, revascularisation, cardiac readmission, stroke) leaving 29 (19%) event-free. The number of diseased vessels was the major determinant of time to first event (p = 0.001) and event-free survival (p = 0.04). Exercise duration was also important in the prediction of time to first event (p = 0.003). Death was influenced by a history of prior MI. CONCLUSION: The favourable initial survival was followed by significant deterioration after nine years. This late attrition is an important treatment target. Furthermore, this study supports risk stratification early after MI combining angiography with non-invasive tools.

Admission plasma glucose: an independent risk factor in nondiabetic women after coronary artery bypass grafting.

OBJECTIVE: To investigate the relationship between admission plasma glucose and 30-day mortality after primary isolated coronary artery bypass grafting (CABG) in nondiabetic patients. RESEARCH DESIGN AND METHODS: All nondiabetic patients with admission plasma glucose measurement undergoing primary isolated CABG from 1993 to 1997 were included in this study. RESULTS: In 878 consecutive patients (155 women), overall mortality was 3.4% (95% CI 2.3-4.8). The mortality rate in women (n = 11; 7.1%, 3.6-12.3) was higher than in men (n = 19; 2.6%, 1.6-4.1) (P = 0.01). There was a positive correlation between plasma glucose and 30-day mortality among women only (P = 0.0001). There was a higher mortality rate in the upper two glucose quartiles (11.7%, 5.5-21.0) compared with the lower two quartiles (2.6%, 3.0-8.9) in the female patients (P = 0.03); a plasma glucose of 6.0 mmol/l separated high- and low-mortality groups. Furthermore, women in the upper two glucose quartiles had a fourfold higher mortality rate than men in the similar quartiles (P = 0.002). Among men, there was no difference in mortality rate across glucose quartiles. In a multivariate analysis, admission plasma glucose, history of thyroid disease, left ventricular ejection fraction <0.35, operation bypass time, and perioperative myocardial infarction were independently associated with mortality. CONCLUSIONS: Women with admission plasma glucose < or =6.0 mmol/l and men across the whole range of glucose values had similar mortality rates after CABG. The surplus female mortality was found only in subjects with plasma glucose >6 mmol/l. Further studies are needed to appraise the possible influence of glucose status on outcome from CABG in nondiabetic subjects.

Experimental pain and psychologic status of patients with chest pain with normal coronary arteries or ischemic heart disease.

BACKGROUND: The cause of chest pain in patients with a normal coronary angiogram (NCA) remains an enigma. Also, it is unclear whether psychosocial factors play a role in the etiology of chest pain in these patients. The objective of the current study was to compare psychosocial factors, clinical pain, and responses to experimental pain in NCA patients, patients with ischemic heart disease (IHD), and healthy control subjects. METHODS: Pain intensity, threshold, and tolerance to cold pressor pain were assessed in 30 NCA patients, 30 IHD patients, and 30 healthy control subjects matched for age, sex, and sociodemographic factors. All subjects completed questionnaires measuring a number of psychosocial factors, including stress, anxiety, depression, extroversion, and neuroticism. NCA and IHD patients also completed questionnaires assessing clinical pain responses and pain-coping strategies. RESULTS: With the exception of a lower tolerance to cold pressor pain of IHD patients (P <.05), no significant differences were found between NCA and IHD patients with respect to other clinical pain measures, psychosocial measures, pain-coping strategies, and other pain-related behaviors. Healthy control subjects differed significantly (P <.05) from both IHD and NCA patients with respect to maximum cold pressor pain, depression, and state anxiety and from IHD patients with respect to intensity of cold pressor pain, threshold to cold pressor pain, and perceived stress. CONCLUSIONS: The results suggest that higher scores on various psychosocial measures in both chest pain groups are related to their pain, rather than being the cause of pain, and do not support a psychogenic explanation for chest pain in the presence of normal coronary arteries.

Axial stretch modifies contractility of porcine coronary arteries by a protein kinase C-dependent mechanism.

Large coronary arteries undergo marked circumferential and axial deformations due to changes in blood pressure and gross movements of the ventricular wall during systole and diastole. The present study was designed to investigate 1) whether axial stretch of large coronary arteries influences the sensitivity to vasoconstrictors, 2) the mechanisms mediating stretch-dependent changes in vascular sensitivity. Endothelium-denuded cylindrical segments from large porcine coronary arteries were studied under isometric conditions using a balloon-based impedance planimetric technique. In segments subjected to a pressure of 60 mmHg, 20% axial stretch caused a left-ward shift of the concentration-response curves for K+ and 5-hydroxytryptamine (5-HT). Enhancement of vascular sensitivity to 5-HT induced by axial stretch was observed also in maximally K+-depolarized coronary arteries. Protein kinase C inhibition by calphostin C (1 microM) slightly decreased the spontaneous resting tone at 60 mmHg and inhibited the leftward shift of the concentration-response curve for 5-HT elicited by axial stretch. These results suggest that axial stretch of the vessel wall enhances the sensitivity of coronary arteries to vasoconstrictors by a protein kinase C-dependent mechanism.

A potential role for endothelin-1 in peripheral vascular disease.

The distribution of endothelin-1 (ET-1) and its receptors (ET(A)/ET(B)) has been studied in segments of femoral artery obtained from patients undergoing operation for peripheral vascular disease (PVD) using a combination of immunohistochemistry and autoradiography. Both receptor subtypes were located on the tunica media of vessel segments, with ET(A)-receptors predominating. Densitometric analysis showed that there was no difference in receptor binding to proximal/distal arterial segments from PVD patients. High-resolution autoradiography identified ET(B) binding to vascular nerves and vasa vasorum, mainly in distal portions of femoral arteries. Immunoreactive ET-1 was also identified that was associated with the vasa vasorum.

Cardiac energy metabolism in patients with chest pain and normal coronary angiograms.

In 70 patients (94% were a consecutive series) with angina pectoris and normal coronary angiograms, we measured cardiac exchange of lactate, glucose, free fatty acids (FFAs), glutamate, alanine, citrate, and oxygen together with coronary sinus blood flow and blood pressure in response to pacing (150 beats/min). Twelve patients had an abnormal exercise stress test; 26 developed ST depression and 46 had chest pain in response to pacing. Sixteen patients had no ST changes (exercise/ pacing) and no pain during pacing. Pacing induced an increase in cardiac carbohydrate extraction and a decrease in FFA extraction in the entire group of patients. Less than 3% of patients had significant cardiac lactate release in response to pacing, and there were no consistent differences in the cardiac metabolic or hemodynamic responses between patient groups. The pacing-induced shift from FFA to carbohydrate extraction probably reflects the cardiac response to an acute workload. A definite sign of cardiac ischemia (lactate production) was a rare finding in these patients and not confined to the demonstration of electrocardiographic signs of ischemia.

Endothelial dysfunction, subangiographic atheroma, and unstable symptoms in patients with chest pain and normal coronary arteriograms.

BACKGROUND: Patients with chest pain and normal coronary arteriograms (CPNA) may present with unstable symptoms and other evidence of ischemia during clinical follow-up. Although repeat angiography usually proves negative, functional assessment of coronary vasomotor abnormalities may provide additional pathophysiologic information. HYPOTHESIS: The study was undertaken to evaluate the relationship between endothelial dysfunction and subangiographic atheroma in patients with CPNA undergoing repeat angiography because of unstable symptoms. METHODS: We investigated nine patients with CPNA (8 women, mean age 57 +/- 9 years) undergoing repeat angiography because of unstable anginal symptoms. After normal angiography, simultaneous coronary epicardial and microvascular vasomotor responses to intracoronary vasodilators [acetylcholine (10(-6) M), adenosine (18 micrograms) and nitroglycerin (300 micrograms)] were investigated in the left anterior descending artery using quantitative angiography and Doppler flow measurements. The presence of subangiographic atheroma was assessed by intravascular ultrasound. RESULTS: Three patients demonstrated proximal and distal epicardial vasoconstriction and a reduction in coronary flow in response to acetylcholine, indicating concordant epicardial and microvascular endothelial dysfunction. These changes were associated with chest pain and ischemic electrocardiographic changes in two patients. None of the remaining patients suffered chest pain in response to intracoronary acetylcholine. Six patients had significant subangiographic disease (intimal thickness > 0.3 mm) on intravascular ultrasound imaging, and multivariate analysis indicated a significant relationship (R2 = 0.89, overall p = 0.001) between the extent of subangiographic disease and both plasma cholesterol concentration and hypertensive history. No significant relationship was demonstrated between endothelial dysfunction and the extent of subangiographic disease. CONCLUSION: Concordant epicardial and microvascular endothelial dysfunction may be pathophysiologically and clinically significant in unstable patients with CPNA but does not appear to be directly related to the extent of subangiographic atheroma.

Functional significance of recruitable collaterals during temporary coronary occlusion evaluated by 99mTc-sestamibi single-photon emission computerized tomography.

OBJECTIVES: The present study evaluated the impact of recruitable collaterals on regional myocardial perfusion measured by 99mtechnetium (Tc)-sestamibi single-photon emission computerized tomography (SPECT) during temporary coronary occlusion and related these estimates to the coronary wedge pressure and electrocardiographic (ECG) ST-segment changes. BACKGROUND: Clinical variables (angina and ECG changes) and intracoronary flow and pressure recordings have indicated a protective role of recruitable collaterals on myocardial perfusion during percutaneous transluminal coronary angioplasty (PTCA). METHODS: Thirty patients (mean age 55 years, SD 9; 20 men) with stable angina pectoris and proximal nonocluding single-vessel left anterior descending coronary artery (LAD)-stenosis scheduled for PTCA were included. Visualization of recruitable collaterals by ipsilateral and contralateral contrast injection, registration of coronary wedge pressure and injection of 99mTc-sestamibi during 90-s LAD occlusions were undertaken. A rest perfusion study was performed within four days before PTCA. As an estimate of the severity of regional hypoperfusion during occlusion, an occlusion/rest count ratio was calculated (mean defect pixel count during occlusion divided by mean pixel count in identical regions at rest). RESULTS: The scintigraphic occlusion/rest count ratio was higher in patients with recruitable collaterals (n = 16), 67 +/- 11%, compared to patients without collaterals (n = 14), 60 +/- 6% (p < 0.05). The occlusion/rest count ratio correlated with the coronary wedge pressure (R2 = 0.34; p < 0.001). The occlusion/rest count ratio was lower, 61 +/- 6%, in patients with ST-segment elevation (n = 23) versus 74 +/- 9% in patients without ST-segment elevation (n = 7) (p < 0.0001). CONCLUSIONS: Using 99mTc-sestamibi SPECT imaging during brief episodes of coronary occlusion, the severity of regional myocardial hypoperfusion was reduced by the presence of recruitable collaterals in a selected patient population with proximal LAD stenoses. Our results demonstrate a protective effect of recruitable collaterals on myocardial perfusion during temporary coronary occlusion.

Vascular reactivity to nifedipine and Ca(2+) in vitro: the role of preactivation, wall tension and geometry.

The purpose of the study was to investigate the influence of preactivation, wall tension and geometry on the reactivity of porcine coronary arteries to nifedipine and extracellular Ca(2+) in vitro. Porcine large coronary arteries were mounted as ring and cylindrical preparations and studied by wire- and balloon-based techniques. The sensitivity and maximal responses to nifedipine were more pronounced in 25 mM K(+) compared to 10 microM prostaglandin F(2alpha)-contracted preparations. Vascular sensitivity to nifedipine and Ca(2+) was enhanced under isometric compared to isobaric conditions. Under isometric conditions in the presence of 25 mM K(+), coronary rings were more sensitive to nifedipine, but less sensitive to Ca(2+) compared to cylindrical segments. In cylindrical segments, circumferential and axial tension increases augmented the extracellular Ca(2+)-dependent spontaneous resting tone and the sensitivity to extracellular Ca(2+). Coronary rings showed no resting tone at various resting tensions. These results suggest that preactivation, wall tension and vessel geometry are important determinants of Ca(2+)-influxes via nifedipine-sensitive voltage-gated Ca(2+) channels. Furthermore, axial wall tension appears to be a modulator of nifedipine-insensitive transmembrane Ca(2+)-influx that may play a role for the tone and reactivity in large coronary arteries.

Elevated endothelin concentrations are associated with reduced coronary vasomotor responses in patients with chest pain and normal coronary arteriograms.

OBJECTIVES: The purpose of this study was to investigate the relationship between arterial and coronary sinus endothelin (ET) concentrations and coronary vasomotor responses during rapid atrial pacing in patients with chest pain and normal coronary arteriograms (CPNA). BACKGROUND: Plasma ET concentrations are significantly higher in CPNA patients than in healthy control subjects. METHODS: We investigated 19 carefully characterized CPNA patients (14 women; mean age 53 +/- 9 years) of whom 10 had positive electrocardiographic responses to exercise. The percentage fall in coronary vascular resistance (%d.CVR) after 10 min of rapid atrial pacing was determined using a thermodilution pacing catheter. Plasma ET concentrations were measured by radioimmunoassay on simultaneously drawn arterial and coronary sinus samples. RESULTS: No significant differences in ET concentrations were observed between men and women, but a strong statistical trend suggested that %d.CVR was lower in women than men (27[23 to 31]% vs. 34[29 to 45]%--median[interquartile range]; p = 0.07). Simple regression analysis including only the women (n = 14) suggested a significant relationship between baseline arterial ET concentrations and %d.CVR (R2 = 0.34; p = 0.06). Furthermore, stepwise multivariate regression analysis of the group as a whole indicated that both gender (p = 0.03) and baseline arterial ET concentration (p = 0.02) were independently predictive of %d.CVR (R2 = 0.44; overall p = 0.02); this relationship predicts that women with high ET levels would have the lowest %d.CVR during pacing. CONCLUSIONS: These data support the hypothesis that elevated ET activity may be associated with reduced coronary flow responses during rapid atrial pacing in CPNA patients.

The influence of transmural pressure and longitudinal stretch on K+- and Ca2+-induced coronary artery constriction.

UNLABELLED: The aim of the study was to investigate transmural pressure and longitudinal stretch modulation of K+- and Ca2+-induced constriction of porcine conductance coronary arteries. In a pressure myograph set-up, left anterior descendent coronary arteries from 70 to 90 kg pigs were investigated at pressures from 20 to 120 mmHg. Longitudinal extension ratio (lambda = L/L0(-1), where L0 is the in situ length and L the examination length) varied between 0.9 and 1.1. Two protocols were carried out: (1) Outer diameter response to maximal depolarization by K+ 125 mM at 20-120 mmHg and lambda at 0.90-1.10. (2) Concentration-response curves with K+ (4.7-125 mM) and Ca2+ (0.05-4.0 mM) at four combinations of P and lambda (P = 100 mmHg, lambda = 0.9; P = 100 mmHg, lambda = 1.1; P = 40 mmHg, lambda = 0.9; p = 40 mmHg, lambda = 1.1). RESULTS: Endothelial function was preserved. A slight (<5% diameter reduction) basal tone and no myogenic response was found. Protocol 1: the constriction to K+ 125 mM was maximal in a wide pressure range from 40 to 120 mmHg. Despite the fact that K+-induced diameter changes were statistically insignificant between 40 and 120 mmHg, there was a linear trend towards smaller diameter changes in this pressure range (r = -0.54, P < 0.01). Stretch influenced constriction at 20 mmHg because lambda = 0.90 and 0.95 resulted in smaller diameter-reductions than lambda = 1.00-1.10 (P < 0.05 for all). Contrastingly, at 120 mmHg the constriction at lambda = 1.10 was smaller than the responses at lambda = 0.90-1.05 (P < 0.05 for all). Protocol 2: EC50 and EC10 values for K+- and Ca2+ were generally higher (more sensitive) at 40 compared with 100 mmHg. Stretch was of no significant importance for EC50 and EC10 at 40 and 100 mmHg. It is concluded that porcine coronary artery constriction to non-metabolized agonists is maximal at 40 mmHg with a trend towards smaller diameter changes with higher pressures. Longitudinal stretch affects responsiveness at pressure extremes.

Musculo-skeletal pathology in patients with angina pectoris and normal coronary angiograms.

PURPOSE: To evaluate the role of the musculo-skeletal apparatus in patients with angina pectoris despite normal coronary angiograms. DESIGN: A survey of patients and controls investigated by blinded observers. SETTING: A tertiary cardiologic referral centre. SUBJECTS: Thirty women and 18 men (mean age 52.9 years) with chest pain of an average duration of 3 years and 11 months were investigated. All had normal resting electrocardiograms. No patients showed evidence of left ventricular hypertrophy or valvular heart disease on echocardiography and all had a normal coronary angiogram. All had left ventricular ejection fraction > 50%, and none had signs of coronary vasospasm. Eighteen healthy persons (10 women and eight men, mean age 51.2 years) served as controls. MAIN OUTCOME MEASURES: The group frequency of chest wall complaints, spinal radiograph and physical examination findings; pressure pain thresholds. RESULTS: The patients had significantly more complaints of pain from the neck, chest, and thoracic spine, and sensations and pain radiating to the arms than the controls. The patients had more degenerative findings on radiograph than the controls, mainly at levels C4-C7. Physical examination showed that abnormal findings were significantly more frequent in patients than in the control group in the anterior and posterior chest wall, in the spine at levels Th1-Th6 and in the muscles of the neck and shoulder girdle. There were no statistically significant differences in pain thresholds or in neurological examination. CONCLUSION: The musculo-skeletal abnormalities observed in the patients could include reflex mechanisms. Whether the abnormal findings are mainly responsible for the angina pectoris symptoms or merely epiphenomena warrants further study.

Relation between zero-stress state and branching order of porcine left coronary arterial tree.

The left common coronary arterial trees of eight pig hearts were dissected. The zero-stress state (the state of the organ when the external loads are removed) of the coronary arteries was determined by first cutting the arteries into short, ring-shaped segments perpendicular to the longitudinal axis of the blood vessel and then making a radial cut. This procedure caused the ring to open into a sector whose opening angle (theta), internal and external lengths (circumferences), and wall thickness were measured. Morphometric and theta data were organized in the framework of a diameter-defined Strahler system. We investigated 4 rings from the left common coronary artery (LCCA), 185 from the left anterior descending artery (LAD) and its branches, and 159 from the left circumflex artery (LCX) and its branches. The inner circumferences of the rings ranged over six orders for the LAD arterial tree and five orders for the LCX arterial tree, corresponding to a diameter range of about one order of magnitude for both arteries. theta demonstrates viscoelastic behavior and was measured 30 min after cutting. Our results show that the inner and outer circumference and the wall thickness increase as geometric sequences with the order number. theta is found to decrease linearly toward the smaller orders with a slope of 7.3 degrees/order in the range of the six largest orders. Strain calculations showed that the inner part of the arterial wall is in compression, whereas the outer part of the wall is in tension in the no-load (zero transmural pressure) state. This study provides basic data on the zero-stress state that are necessary for understanding the mechanics of the coronary artery.

A new method for combined isometric and isobaric pharmacodynamic studies on porcine coronary arteries.

1. The principal aim of the present study was to explore the isometric and isobaric capacity of a new intravascular technique, impedance planimetry, in basic pharmacodynamic investigations on porcine isolated epicardial coronary arteries. 2. The balloon-based catheter technique provides simultaneous measurements of luminal cross-sectional area and pressure. Sources of errors that may influence the accuracy of measurements were evaluated in detail. 3. Under isometric conditions, the stretch ratio-tension diagram showed typical developments of resting and active tensions of the smooth muscle when exposed to alternating maximal K+ depolarization and mechanical stretching. The mean (+/- SEM) maximum active tension was 28.43 +/- 1.72 mN/mm, which was reached at a stretch ratio of 1.26 +/- 0.02, corresponding to a resting tension of 10.50 +/- 0.53 mN/mm (n = 7). The concentration-response relationship to K+ at optimal basal tension was characterized by a mean (+/- SEM) pD2 value of 1.67 +/- 0.01 (n = 7). 4. Under isobaric conditions in the pressure range 40-140 mmHg, the method allowed the investigation of active vascular responses to partial K+ depolarization. The maximal active response to 25 mmol/L K+ was found at the transmural pressure of 60 mmHg (n = 7). To obtain full K+ concentration-response curves, a basal tension corresponding to a transmural pressure of 120 mmHg was required. The mean (+/- SEM) pD2 value for the concentration-response relationship to K+ was 1.53 +/- 0.01 (n = 10). 5. The vascular sensitivities to cumulatively added K+ and various agonists, such as acetylcholine, 5-hydroxytryptamine and noradrenaline, obtained from the same vessel segment at the same initial conditions corresponding to 120 mmHg were significantly higher with the isometric than with the isobaric approach. 6. The results of the present study suggest that impedance planimetry could be a useful tool in pharmacological and physiological investigations of medium-sized arteries, both under isometric and isobaric conditions.

Long-term outcome of spinal cord electrical stimulation in patients with refractory chest pain.

BACKGROUND AND HYPOTHESIS: Treatment of patients with refractory chest pain remains a challenge. In this study, the long-term clinical effects of spinal cord electrical stimulation were evaluated in 10 consecutive male patients (mean age 53.7 years) with chronic chest pain in a prospective observational study. METHODS: After placement of the electrode in an epidural position and before implantation of the device, patients were subjected to clinical evaluation, including atrial pacing, in order to document significant antianginal effects. RESULTS: Spinal cord electrical stimulation abolished or improved pacing time to angina by more than 50% in seven of the patients who subsequently had the device implanted. In three of these patients, the system was ineffective after a period of 3-9 months despite paresthesia in the area of anginal pain with electrical stimulation. The effects of treatment remained satisfactory in the remaining patients (40%) after a mean follow-up of 60 (45-72) months. Thus, a long-lasting clinical response was able to be predicted in 57% of the patients. CONCLUSION: Spinal cord electrical stimulation is one of the few therapeutic options in inoperable patients with refractory chest pain.