Spinal Cord Electrical Stimulation for Refractory Angina Treatment

Cardiovascular disease (CVD) is the main cause of death worldwide, including in Brazil. Angina pectoris is a challenging disease because its clinical manifestation is not always related to the degree of obstruction. Visceral pain fromany source can be totally disabling. It influences all aspects of the life of a patient and it can be one of the main causes of absence from work and of family disruption. Spinal cord electrical stimulation (SCES) has been traditionally applied for the treatment of neuropathic pain, with good to excellent results. Visceral pain syndrome can be as debilitating and disabling as somatic or neuropathic pain; however, there seems to be a lack of consensus on the appropriate treatment and strategies for these disorders. Themajor difference of SCES for visceral pain, compared to postlaminectomy syndrome or to regional complex syndrome, is the number of stimulated dermatomes. In most viscera, the somatotopic arrangement has two to four medullar levels, sometimes requiring laterality. After reviewing the literature, we have concluded that SCES is now a viable, low-risk option with satisfactory results for the treatment of neuropathic and visceral pain; therefore, it can be used in refractory angina after the failure of standard therapy. However, further studies are required to increase the application and efficacy of this procedure in the clinical practice.

Ginkgo Biloba extract for angina pectoris: a systematic review.

OBJECTIVE: To evaluate the efficacy and safety of Ginkgo Biloba extract for patients with angina pectoris according to the available evidence. METHODS: Electronic databases were searched for all of the randomized controlled trials (RCTs) of angina pectoris treatments with Ginkgo Biloba extract, either alone or combined with routine Western medicine (RWM), and controlled by untreated, placebo, Chinese patent medicine, or RWM treatment. The RCTs were retrieved from the following electronic databases: PubMed/MEDLINE, ProQuest Health and Medical Complete, Springer, Elsevier, and ProQuest Dissertations and Theses, Wanfang Data, China National Knowledge Infrastructure (CNKI), VIP database, China Biology Medicine (CBM), Chinese Medical Citation Index (CMCI), from the earliest database records to December 2012. No language restriction was applied. Study selection, data extraction, quality assessment, and data analyses were conducted according to the Cochrane standards. RevMan 5.1.0 provided by Cochrane Collaboration The data were analysed by using. RESULTS: A total of 23 RCTs (involving 2,529 patients) were included and the methodological quality was evaluated as generally low. Ginkgo Biloba extract with RWM was more effective in angina relief and electrocardiogram improvement than RWM alone. Reported adverse events included epigastric discomfort, nausea, gastrointestinal reaction, and bitter taste. CONCLUSIONS: Ginkgo Biloba extract may have beneficial effects on patients with angina pectoris, although the low quality of existing trials makes it difficult to draw a satisfactory conclusion. More rigorous, high quality clinical trials are needed to provide conclusive evidence.

Spasm provocation tests performed under medical therapy: a new approach for treating patients with refractory coronary spastic angina on emergency admission.

Objective There are no objective methods for evaluating the severity of vasospasms in patients with refractory coronary spastic angina (R-CSA) under adequate medical therapy. We examined whether spasm provocation tests performed under adequate medication are useful for evaluating the severity of disease in R-CSA patients on emergency admission. Methods and Results We performed spasm provocation tests before and after the administration of medical therapy in eight R-CSA patients, including one ventricular fibrillation survivor (VF-S) and seven patients with unstable angina (UAP) on emergency readmission. We also performed these tests only after medical therapy on urgent admission in four R-CSA patients, including two patients with UAP, one patient with VF-S and one patient with acute coronary syndrome. All 12 R-CSA patients had been medicated with ≥ 2 vasodilator drugs. Positive coronary spasms were defined as >99% transient narrowing. The coronary artery spasms disappeared in three patients under medication, and mitigation of vasospasticity was observed in three patients. In these six cases we continued the same medications. Meanwhile in two patients, we recommended a consultation for psychosomatic medicine. In contrast, the remaining six R-CSA patients exhibited higher levels of vasospasticity, irrespective of the administration of aggressive medical therapy, in which the doses of vasoactive drugs were increased in order to suppress coronary artery spasms. Conclusion In some R-CSA patients on emergency admission, performing spasm provocation tests under medical therapy is useful for determining the subsequent treatment strategy. Therefore, this test may become a new tool in the treatment of R-CSA.

Analysis of the effects of electroacupuncture at the pericardium 6 acupoint on heart function in patients with angina using equilibrium radionuclide angiocardiography quantity analysis technique.

OBJECTIVE: To analyze changes in cardiac function indices after electroacupuncture (EA) at the pericardium 6 (PC-6) acupoint using the equilibrium radionuclide angiocardiography (ERNA) quantity analysis technique. DESIGN: Analysis of clinical outcomes after EA at PC-6 measured by ERNA. SETTING: The study was conducted in a hospital. PARTICIPANTS: 31 participants (17 patients with angina and 14 healthy volunteers). INTERVENTION: The study used ERNA to study outcomes of EA at PC-6 on heart function. OUTCOME MEASURE: ERNA images were taken before the treatment (T0), at the end of the treatment (T1), and 20 minutes after the treatment (T2) and then processed. RESULTS: Regional left ventricular ejection fraction (REF) increased after EA in the angina and control groups. REF at T2 was significantly higher than at T1 in the angina group (p<.01). In the control group, REF was higher at T1 than at T0 (p<.01) but did not differ between T1 and T2 (p=.08). The REF deviation among ventricular regions in the angina group was significantly greater than that in the control group at T0 (p<.01) but was reduced to the level of that in control group after EA (p=.52). Peak filling rate was lower in the angina group than in controls at all three time points (all p<.01). After EA, peak filling rate increased markedly in the angina group but not in the control group. The cardiac cycle was shorter in the angina group than in the control group at T0 (p<.01) and increased after EA. The cardiac cycle of the control group did not change. CONCLUSION: Effects of EA at PC-6 on heart function can be detected and quantified by ENRA.

Effectiveness of music interventions for women with high anxiety during coronary angiographic procedures: a randomized controlled.

The purpose was to investigate if women with high pre-procedural anxiety reported higher degree of relaxation and comfort if listening to music during coronary angiographic procedures. A prospective randomized controlled trial was used included 68 patients undergoing coronary angiography and/or PCI. The women were allocated to receive calming music and standard care or standard care only. Relaxation, environmental sound and discomfort associated with lying still were assessed. There was significantly more positive impression of the sound environment and less discomfort associated with lying still in women listening to music in comparison to women who received only standard care. No effect in relaxation was found.

[Validation of patients' knowledge after informed consent prior to coronary angiography]. / Überprüfung des Patientenwissens nach Aufklärung vor invasiver Koronarangiographie.

BACKGROUND AND OBJECTIVE: The informed consent of the patient is required before any medical intervention can be done. The impact of the provided information on the subsequent knowledge of the patient is regularly questioned. In the present investigation we aimed to determine the knowledge of the patients about invasive coronary angiography (CA) after they had been optimally vs. standard vs. not at all informed. PATIENTS AND METHODS: 300 consecutive patients who were admitted for planned CA were included. Of these, 150 in-patients were informed by especially trained physicians one day before CA and 50 out-patients were informed by their general practitioner or cardiologist several days before admission. 100 in-patients were included before they were informed. In a standardized interview the predefined knowledge of the patients was assessed by an independent physician before CA in previously informed patients and after hospital admission in non-informed patients. RESULTS: The differences in knowledge between informed in- and out-patients were low. Especially their knowledge about potential complications was not different. Generally, patients could remember less serious complications better than life-threatening ones. Two previously informed patients (1 %) affirmed that they were not informed. The knowledge of non-informed patients was much lower than the knowledge of patients who had been informed. CONCLUSION: The knowledge and remembrance of patients after having detailed information about medical interventions is limited. Optimization of the informative interview did not really improve this knowledge. In contrast to non-informed patients the provided information did, however, increase the knowledge.

A multi-center randomized double-blind placebo-controlled trial of Xiongshao Capsule in preventing restenosis after percutaneous coronary intervention: a subgroup analysis of senile patients.

OBJECTIVE: To evaluate the safety and efficacy of Xiongshao Capsule (XS), consisting of Chuangxiongol and paeoniflorin, in preventing restenosis after percutaneous coronary intervention (PCI) in senile coronary heart disease (CHD) patients. METHODS: A multi-center, randomized, double-blind, placebo-controlled trial was conducted. A total of 335 CHD patients were randomly assigned to treatment with oral administration of XS, or a placebo for 6 months after successful PCI. A clinical follow-up was performed at 1, 3 and 6 months after PCI and an angiographic follow-up was scheduled at 6 months. The primary endpoint was angiographic restenosis defined as a luminal stenosis ≥ 50% in follow-up. The secondary endpoints were combined incidence of death, target lesion nonfatal myocardial infarction, repeat target-vessel angioplasty, and coronary artery bypass graft surgery (CABG). The follow-up for the above clinical endpoint events was continued to 1 year after PCI. RESULTS: The subgroup analysis of 152 senile patients (68 cases angiographic follow-up) showed that the restenosis rates tended to reduce in the XS group as compared with that in the placebo group (24.32% vs. 38.71%, P > 0.05), and the minimum lumen diameter (MLD) significantly increased in the follow-up (2.15 ± 0.84 for XS vs. 1.73 ± 0.91 for placebo, P < 0.05). The incidence of recurrent angina at 3 and 6 months after PCI was also significantly reduced in the XS group (4.11% and 12.33%) as compared with those in the placebo group (17.72% and 43.04%), but there was no significant difference in the combined incidence of clinical outcomes (6.85% in the XS group vs. 11.39% in the placebo group, P > 0.05). No significant adverse reactions occurred within the 6-month follow-up period in the XS group. CONCLUSION: Administration of XS in addition to standardized Western medication for 6 months is demonstrated to be safe and effective in reducing post-PCI recurrent angina and inhibiting luminal restenosis after PCI in senile CHD patients.

Stable angina pectoris: head-to-head comparison of prognostic value of cardiac CT and exercise testing.

PURPOSE: To determine and compare the prognostic value of cardiac computed tomographic (CT) angiography, coronary calcium scoring, and exercise electrocardiography (ECG) in patients with chest pain who are suspected of having coronary artery disease (CAD). MATERIALS AND METHODS: This study complied with the Declaration of Helsinki, and the local ethics committee approved the study. Patients (n = 471) without known CAD underwent exercise ECG and dual-source CT at a rapid assessment outpatient chest pain clinic. Coronary calcification and the presence of 50% or greater coronary stenosis (in one or more vessels) were assessed with CT. Exercise ECG results were classified as normal, ischemic, or nondiagnostic. The primary outcome was a major adverse cardiac event (MACE), defined as cardiac death, nonfatal myocardial infarction, or unstable angina requiring hospitalization and revascularization beyond 6 months. Univariable and multivariable Cox regression analysis was used to determine the prognostic values, while clinical impact was assessed with the net reclassification improvement metric. RESULTS: Follow-up was completed for 424 (90%) patients; the mean duration of follow-up was 2.6 years. A total of 44 MACEs occurred in 30 patients. Four of the MACEs were cardiac deaths and six were nonfatal myocardial infarctions. The presence of coronary calcification (hazard ratio [HR], 8.22 [95% confidence interval {CI}: 1.96, 34.51]), obstructive CAD (HR, 6.22 [95% CI: 2.77, 13.99]), and nondiagnostic stress test results (HR, 3.00 [95% CI: 1.26, 7.14]) were univariable predictors of MACEs. In the multivariable model, CT angiography findings (HR, 5.0 [95% CI: 1.7, 14.5]) and nondiagnostic exercise ECG results (HR, 2.9 [95% CI: 1.2, 7.0]) remained independent predictors of MACEs. CT angiography findings showed incremental value beyond clinical predictors and stress testing (global χ(2), 37.7 vs 13.7; P < .001), whereas coronary calcium scores did not have further incremental value (global χ(2), 38.2 vs 37.7; P = .40). CONCLUSION: CT angiography findings are a strong predictor of future adverse events, showing incremental value over clinical predictors, stress testing, and coronary calcium scores. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11110744/-/DC1.

Myocardial perfusion after one year of spinal cord stimulation in patients with refractory angina.

AIM: Spinal cord stimulation (SCS) is recommended for patients with coronary artery disease (CAD) and refractory angina. We used positron emission tomography (PET) to investigate the long-term effect of SCS on regional myocardial perfusion in patients suffering from angina pectoris refractory to medical treatment and without option for coronary intervention. PATIENTS, METHODS: We analyzed data of 44 patients with stable CAD (91% three vessel disease). At baseline, we determined coronary flow reserve (CFR) using 13N-ammonia-PET and myocardial viability with 18F-FDG. SCS was performed for one year (Medtronic Itrell III or Synergy, Düsseldorf, Germany). During follow-up, no cardiac interventions were necessary and no myocardial infarctions occurred. At one year follow-up, CFR was measured again. RESULTS: In the majority of patients (77%), SCS led to an improvement of clinical symptoms. CFR did not change significantly during follow-up. Subjective improvement did not correlate with an increase of CFR. CONCLUSIONS: Despite its clinical effect, SCS does not have a direct impact on CFR in patients with stable CAD. According to our results, the pain relief is not due to an improvement of the myocardial blood supply.

Muscular tenderness in the anterior chest wall in patients with stable angina pectoris is associated with normal myocardial perfusion.

OBJECTIVE: This study examines the relationship between the existence of chest wall tenderness evoked by palpation and the absence of ischemic heart disease defined by myocardial perfusion imaging in patients with known or suspected stable angina pectoris. METHODS: Two hundred seventy-five patients were recruited. Myocardial perfusion imaging was performed on 273 of the subjects. Chest pain was classified according to type by criteria given by the Danish Society of Cardiology and severity by the Canadian Cardiovascular Society. Pectoralis major and pectoralis minor were palpated for tenderness using a standardized procedure. RESULTS: The association between tenderness and myocardial perfusion imaging (normal vs abnormal) produced an odds ratio (OR) of 2.24 (confidence interval, 1.26-3.99; P = .009). The OR was the same magnitude and significance when stratified by sex, age, type of pain, or class. When adjusting simultaneously for sex, age, type of pain, and class, the association between tenderness and myocardial perfusion imaging (normal vs abnormal) was still present (OR = 2.57; confidence interval, 1.342-4.902; P = .004). CONCLUSION: Presence of tenderness in the anterior chest wall is associated with a higher prevalence of normal myocardial perfusion imaging in patients with known or suspected angina pectoris, and this association cannot be explained by a common association to age, sex, or pain.

Coronary and aortic calcifications inter-relationship in stable angina pectoris: A Coronary Disease Trial Investigating Outcome with Nifedipine GITS (ACTION)--Israeli spiral computed tomography substudy.

BACKGROUND: Coronary heart disease and ischemic stroke are among the leading causes of morbidity and mortality in adults, and cerebrovascular disease is associated with the presence of symptomatic and asymptomatic CHD. Several studies noted an association between coronary calcification and thoracic aorta calcification by several imaging techniques, but this association has not yet been examined in stable angina pectoris patients with the use of spiral computed tomography. OBJECTIVES: To examine by spiral CT the association between the presence and severity of CC and thoracic aorta calcification in patients with stable angina pectoris. METHODS: The patients were enrolled in ACTION (A Coronary Disease Trial Investigating Outcome with Nifedipine GITS) in Israel. The 432 patients (371 men and 61 women aged 40-89 years) underwent chest CT and were evaluated for CC and aortic calcification. RESULTS: CC was documented in 90% of the patients (n = 392) and aortic calcification in 70% (n = 303). A significant association (P < 0.05) was found between severity of CC and severity of aortic calcification (as measured by area, volume and slices of calcification). We also found an association between the number of coronary vessels calcified and the presence of aortic calcification: 90% of patients with triple-vessel disease (n = 157) were also positive for aortic calcification (P < 0.05). Age also had an effect: 87% of patients > 65 years (n=219) were positive for both coronary and aortic calcification (P = 0.005) while only 57% < or = 65 (n = 209) were positive for both (P = 0.081). CONCLUSIONS: Our study demonstrates a strong association between the presence and severity of CC and the presence and severity of calcification of thoracic aorta in patients with stable angina pectoris as detected by spiral CT.

[Relationship between pathological changes of coronary artery and severity of Xiongbi syndrome].

OBJECTIVE: To study the relationship between the outcome of coronary angiography (CAG) and the severity of Xiongbi syndrome diagnosed according to "Guiding principle for clinical study on new traditional Chinese medicine in treating Xiongbi (angina pectoris)" (abbreviated as the principle). METHODS: Severity of Xiongbi syndrome in 207 patients were graded according to the principle and they were examined with CAG by Judkins methods. The relationship between the outcome of CAG and severity of Xiongbi syndrome was analyzed. RESULTS: Abnormal rate of ECG was markedly higher in patients with lesion involving 1 or 2 branches of coronary artery than that in patients without coronary artery lesion (P < 0.05), while no significant difference was found in that between patients with multiple-branches lesions and those without lesion. Comparison of Xiongbi syndrome severity showed that there was remarkable difference between patients with normal coronary artery and those with lesions involving different branches (P < 0.01), but no difference among patients with 1 or 2 branches and those with multiple-branches lesions; on the contrary, mild Xiongbi syndrome took up the highest rate (37%) in patients with multiple-branches lesions, and the rate was lower along with higher severity. CONCLUSION: There was no positive relationship between severity of Xiongbi syndrome and that of coronary artery disease.

[Successful off-pump coronary artery bypass for a patient with aplastic anemia].

We report a 61-year-old man with aplastic anemia who underwent successful off-pump coronary artery bypass (OPCAB) after being admitted for angina pectoris. Coronary angiography showed severe stenosis of the left main coronary artery. Preoperative WBC was 2,200/microl, neutrophil 704/microl, Hb 8.1g/dl, and PLT 16,000/microl. We conducted OPCAB on double vessels using left internal thoracic and radial artery grafts. Thirty units of platelets were transfused intraoperatively with little perioperaive hemorrhage. Because of high grade fever, we injected 150 microg granulocyte colony-stimulating factor (G-CSF) every 3 days postoperatively to prevent major infection. The combination of appropriate perioperative management and OPCAB yielded an effective result for a patient with severe hematological disorders causing pancytopenia.

[Spinal cord stimulation in refractory angina pectoris -- a case description]. / Stymulacja rdzenia kregowego w krancowej dusznicy bolesnej -- opis przypadku.

Spinal cord stimulation (SCS) is one of the methods for treating angina pectoris and has been used since 1985. Patients with refractory angina pectoris despite optimal medication and revascularisation procedures are suitable for the SCS. This kind of treatment is not common in Poland. This article reports the first case of a patient with ischaemic heart disease treated with spinal cord stimulation in the Clinical Department of Neurosurgery in the Military Clinical Hospital in Bydgoszcz. The procedure was based on epidural implantation of the electrode at the level of Th1-Th2 and connection with the impulse generator located subcutaneously. As a result of the applied stimulation reduction of the anginal pain was achieved.

Adrenomedullin causes coronary vasodilation in humans: effects of inhibition of nitric oxide synthesis.

Experimental studies have shown that adrenomedullin (AM) causes vasodilation, in part, mediated by endothelium-derived nitric oxide (NO). However, it remains to be clarified how NO is involved in AM-induced coronary vasoreactivity in humans. We examined whether NO contributes to the vasodilatory effects of adrenomedullin on human coronary arteries. In 10 patients with angiographically normal coronary arteries, adrenomedullin (low dose: 1 ng/kg/min; high dose: 10 ng/kg/min) was infused into the left coronary ostium before and after an infusion of N-monomethyl-L-arginine (L-NMMA, 40 micromol/min for 5 min), an NO synthase inhibitor. Coronary diameter and coronary blood flow (CBF) were evaluated by quantitative angiography and Doppler flow velocity measurements. Changes in these parameters in response to adrenomedullin were expressed as percent changes from baseline values. Adrenomedullin at a high dose dilated coronary arteries (3.7+/-0.5%, P<0.001). Adrenomedullin increased the coronary blood flow at both doses (low: 55.7+/-13.9%, P<0.01; high: 48.8+/-9.8%, P<0.001). After the infusion of L-NMMA, adrenomedullin-induced coronary vasodilation and increase in coronary blood flow were attenuated. These findings suggest that adrenomedullin dilates human coronary arteries through an increase in NO production, at least in part.

Effect of nifedipine on C-reactive protein levels in the coronary sinus and on coronary blood flow in response to acetylcholine in patients with stable angina pectoris having percutaneous coronary intervention.

The effects of nifedipine on inflammation and endothelial function in the coronary circulation were studied in patients who had angina pectoris (n = 17). Long-term treatment with nifedipine (nifedipine CR, 20 mg/day for 4 months) decreased levels of C-reactive protein in the coronary sinus (from 0.35 +/- 0.09 mg/dl to 0.07 +/- 0.01 mg/dl, mean +/- SEM, p <0.05) and enhanced acetylcholine-induced increases in coronary blood flow. Thus, nifedipine is effective in decreasing inflammation and incresing endothelial function in the coronary circulation.

[Importance of spinal cord stimulation in the treatment of refractory angina]. / Il ruolo della stimolazione spinale nel trattamento dell'angina refrattaria.

A small non-quantified number of patients is reported to be affected by forms of angina pectoris already treated by traditional therapy but no longer able to achieve better results by drugs or surgery: this is called "refractory angina". Treatments like external counterpulsation, transmyocardial laser revascularization, stem cell transplantation or spinal cord stimulation may be suitable for these patients. The analysis of major studies on spinal cord stimulation based on exercise ECG, Holter monitoring and positron emission tomography, has shown a reduction in anginal attacks and in nitroglycerin pills. Though in small figures, an improved perfusion of the ischemic areas, an increase in the time of ischemia and cardiac mortality comparable to bypass surgery as well as a better quality of life and lower costs with respect to traditional treatment are also evident. Patients who are at high risk of mortality for bypass surgery, and who cannot receive significant benefits from revascularization or improved pharmacological therapy are candidate to spinal cord stimulation. Spinal cord stimulation is safe and effective in about 70% of patients. Some issues have not been investigated yet: the clinical characteristics of "non-responders" and the possibility of avoiding sudden cardiac death in stimulated patients.