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REFRACTORY ANGINA : Definition, epidemiology, and management

REFRACTORY ANGINA : Definition, epidemiology, and management. Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista “Molinette” Università di Torino. Congresso Nazionale della Società Italiana di Cardiologia – Roma, 17 Dicembre 2007 (h 15.00-15.10). Learning goals.

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REFRACTORY ANGINA : Definition, epidemiology, and management

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  1. REFRACTORY ANGINA : Definition, epidemiology, and management Giuseppe Biondi-Zoccai Ospedale S. Giovanni Battista “Molinette” Università di Torino Congresso Nazionale della Società Italiana di Cardiologia – Roma, 17 Dicembre 2007 (h 15.00-15.10)

  2. Learning goals What is refractory angina? -> Definition Does refractory angina really exist? -> Epidemiology Can I do anything about it? -> Management

  3. Learning goals What is refractory angina? -> Definition

  4. Mechanism of angina pectoris LIMBIC SYSTEM AUTONOMIC NERVOUS SYSTEM ? MECHANICAL AND CHEMICUAL STIMULI DeJongste et al, Heart 2004

  5. Refractory angina: scope of the problem INCOMPLETE REVASCULARIZATION RECURRENT ANGINA REFRACTORY ANGINA MICROVASCULAR DYSFUNCTION Abbate et al, Eur Heart J 2007

  6. Recurrent angina: a true challenge Abbate et al, Eur Heart J 2007

  7. (In)complete revascularization

  8. Microvascular dysfunction Lanza, Heart 2007

  9. Refractory angina: definitions Occurrence of chest pain due to myocardial ischemia in a patient with severe coronary artery disease who cannot be managed adequately by lifestyle adjustment or medical therapy and who are not candidates for revascularization (interventional or surgical) 1 ACC/AHA 2002 Guidelines 2 DeJongste et al, Heart 2004

  10. Refractory angina: definitions A chronic (>3 months) condition characterized by the presence of angina caused by coronary insufficiency in the presence of CAD which cannot be controlled by a combination of medical therapy, PTCA and CABG. The presence of reversible myocardial ischemia should be clinically established to be the cause of the symptoms. 3 Mannheimer et al, Eur Heart J 2002

  11. Learning goals Does refractory angina really exist? -> Epidemiology

  12. US burden of refractory angina Yang et al, MCP 2004

  13. US burden of refractory angina Yang et al, MCP 2004

  14. EU burden of refractory angina

  15. EU burden of refractory angina Approximately 7% of people between 45 and 74 years suffer from angina pectoris. At least 14% of those in whom coronary revascularization is indicated are ineligible for it. Of all those with angina, 5-10% will develop refractory angina. This amounts to 30-50,000 persons/year. Lenzen et al, EJCN 2006; Mannheimer et al, Eur Heart J 2002

  16. Angina despite optimal therapy Boden et al, NEJM 2007

  17. Angina despite optimal therapy †p<0.05 at 1 and 3 years, but not at 5 years; ¶P<0.001 favoring PCI at all time points Boden et al, NEJM 2007

  18. Reasons for not performing PTCA/CABG DeJongste et al, Heart 2004

  19. Typical patient features DeJongste et al, Heart 2004

  20. Learning goals Can I do anything about it? -> Management

  21. How about angiogenesis? Why don’t we ask him what he wants? I’ve got this great new operation- I think it’ll help you Thanks Doc (?) The doctor-centered approach VS The patient-centered approach

  22. The patient-centered approach • Level 1 • Tell patients about procedure related morbidity and mortality and proceed • Level 2 • Inform patients of risks and benefits in dialogue and help them come to a decision • Level 3 • Don’t take symptoms for granted. What really is the problem?

  23. The approach to the patient with refractory angina Pain history; is the chest pain angina? Assess red flags (unstable angina, prognostically important disease) Optimise anti-anginal therapy Assess and address angina beliefs and fears Assess expectations in dialogue

  24. Maximize drug therapy

  25. The NORTHERN Trial of VEGF in refractory angina Stewart et al, TCT 2007

  26. Referral to an experienced interventionist

  27. Referral to an experienced cardiac surgeon

  28. Still a role for PTCA/CABG: the MASS II Trial Hueb et al, Circ 2007

  29. Newer treatments for refractory angina

  30. One-hour new patient appointment covering medical history, examination, education & distribution of patient information sheets Individual psychology covering relaxation techniques, and cardiac health anxieties. Usually 4 – 6 sessions TENS machine training from specialist nurses Follow up pain medical appointment to assess outcome of the first 2 treatment modalities. Assessment for stellate ganglion blockade Stellate ganglion block Medical review Cardiology review to exclude new disease Paravertebral block Medical review Implantable therapies: Spinal cord stimulation Intrathecal delivery systems Full angina pain management programme Management of refractory angina: the Greater Manchester Experience Opioid analgesics TENS=Transcutaneous Electrical Nerve Stimulator

  31. Promising role of spinal cord stimulation

  32. Promising role of spinal cord stimulation

  33. Take home messages

  34. We must be ready to look for and listen to patients with refractory angina

  35. Don’t be shy and truly maximize medical therapy

  36. A comprehensive and individualized approach is likely more successful

  37. A comprehensive and individualized approach is likely more successful DeJongste et al, Heart 2004

  38. For further slides on these topics please feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

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