![]() ![]() However, this treatment is no longer recommended with a current class of recommendation III and level of evidence A. Previously transmyocardial revascularization was a therapy used in patients with RAP. ![]() 4 The treatment options that are currently available for patients with RAP are: (i) enhanced external counterpulsation with class of recommendation IIb and level of evidence B, (ii) extracorporeal shockwave therapy (no class of recommendation), (iii) coronary sinus constriction (Reducer device) with class of recommendation IIb and level of evidence B, (iv) gene therapy (no class of recommendation), (v) autologous cell therapy (no class of recommendation), and (vi) neuromodulation ( Figure 1). ![]() The main concern outlined in the guidelines is the varying levels of evidence with regard to safety and efficacy of these potential treatment modalities, which ranges from non-existent to promising. The 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of chronic coronary syndromes describe a growing number of potential treatment options for RAP. It has been acknowledged that this growing patient population have a ‘therapy resistant condition’, but that there are additional ‘last resort’ treatment possibilities. 3 Confirming that a significant number of patients with CAD have RAP and that these numbers are continuing to grow. 2 It has also been estimated that 6–14% of patients undergoing a diagnostic coronary angiogram (CAG) due to angina pectoris meet the definition of RAP with no intervention options. 2 On a yearly basis, 30 000–50 000 new cases of RAP are reported in Europe and 50 000–100 000 new cases in the USA. It has been estimated that 5–10% of patients with stable CAD have RAP, with absolute numbers of up to 1.8 million people in the USA. The number of patients with RAP has been growing in the last years due to a combination of more complex coronary artery disease (CAD), co-morbidities and the advancing age of the general population. Chronic is defined as a duration of more than 3 months’. The presence of reversible myocardial ischaemia should be clinically established to be the cause of symptoms. Refractory angina pectoris (RAP), first defined in 2002 by Mannheimer et al., 1 is ‘a chronic condition characterized by the presence of angina caused by coronary insufficiency in the presence of coronary artery disease which cannot be controlled by a combination of medical therapy, angioplasty and coronary bypass surgery. Refractory angina pectoris, Spinal cord stimulation, Coronary artery disease Introduction A comprehensive overview is given on the history, proposed mechanism of action, safety, efficacy, and current use of SCS. The aim of this review is to give an overview of neuromodulation as treatment modality for patients with RAP. One such last-resort treatment option is spinal cord stimulation (SCS) with a Class of recommendation IIB, level of evidence B in the 2019 European Society of Cardiology guidelines for the diagnosis and management of chronic coronary syndromes. There are currently few treatment options for patients with RAP. RAP is defined as a chronic disease (more than 3 months) characterized by diffuse CAD in the presence of proven ischaemia which is not amendable to a combination of medical therapy, angioplasty, or coronary bypass surgery. In absolute numbers, there are 50 000–100 000 new cases of RAP each year in the USA and 30 000–50 000 new cases each year in Europe. Current estimates indicate that 5–10% of patients with stable CAD have RAP. The number of patients with coronary artery disease (CAD) who have persisting angina pectoris despite optimal medical treatment known as refractory angina pectoris (RAP) is growing. ![]()
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