RESUMEN
Despite optimal combination of guideline-directed anti-ischemic therapies and myocardial revascularization, a substantial proportion of patients with stable coronary artery disease continues to experience disabling symptoms and is often referred as "no-option." The appraisal of the pathways linking ischemia to symptom perception indicates a complex model of heart-brain interactions in the generation of the subjective anginal experience and inspired novel approaches that may be clinically effective in alleviating the angina burden of this population. Conversely, the prevailing ischemia-centered view of angina, with the focus on traditional myocardial revascularization as the sole option to address ischemia on top of medical therapy, hinders the experimental characterization and broad-scale clinical implementation of strongly needed therapeutic options. The interventionist, often the first physician to establish the diagnosis of refractory angina pectoris (RAP) following coronary angiography, should be aware of the numerous emerging technologies with the potential to improve quality of life in the growing population of RAP patients. This review describes the current landscape and the future perspectives on nonpharmacological treatment technologies for patients with RAP, with a view on the underlying physiopathological rationale and current clinical evidence.
Asunto(s)
Angina de Pecho/terapia , Enfermedad de la Arteria Coronaria/terapia , Contrapulsación , Terapia por Estimulación Eléctrica , Tratamiento con Ondas de Choque Extracorpóreas , Terapia Genética , Corazón/inervación , Terapia por Láser , Trasplante de Células Madre , Angina de Pecho/genética , Angina de Pecho/metabolismo , Angina de Pecho/fisiopatología , Animales , Encéfalo/metabolismo , Encéfalo/fisiopatología , Enfermedad de la Arteria Coronaria/genética , Enfermedad de la Arteria Coronaria/metabolismo , Enfermedad de la Arteria Coronaria/fisiopatología , Circulación Coronaria , Contrapulsación/efectos adversos , Terapia por Estimulación Eléctrica/efectos adversos , Metabolismo Energético , Tratamiento con Ondas de Choque Extracorpóreas/efectos adversos , Terapia Genética/efectos adversos , Humanos , Terapia por Láser/efectos adversos , Miocardio/metabolismo , Trasplante de Células Madre/efectos adversos , Resultado del TratamientoRESUMEN
Following an acute coronary syndrome (ACS), heightened predisposition to atherothrombotic events may persist for years. Advances in understanding the pathobiology that underlies this elevated risk furnish a mechanistic basis for devising long-term secondary prevention strategies. Recent progress in ACS pathophysiology has challenged the focus on single "vulnerable plaques" and shifted toward a more holistic consideration of the "vulnerable patient," thus highlighting the primacy of medical therapy in secondary prevention. Despite current guideline-directed medical therapy, a consistent proportion of post-ACS patients experience recurrent atherothrombosis due to unaddressed "residual risk": contemporary clinical trials underline the pivotal role of platelets, coagulation, cholesterol, and systemic inflammation and provide a perspective on a personalized, targeted approach. Emerging data sheds new light on heretofore unrecognized residual risk factors. This review aims to summarize evolving evidence relative to secondary prevention of atherothrombosis, with a focus on recent advances that promise to transform the management of the post-ACS patient.