Options When Revascularization Isn’t One; Role of the Heart Team for Refractory Angina
ACCEL | We know a lot about when coronary artery bypass graft (CABG) surgery is appropriate and superior to other options and there are also indications for choosing percutaneous coronary intervention (PCI). Lesion complexity is an essential consideration for stenting, of course, whereas patient comorbidity is an essential consideration for CABG.
But what about patients with ischemic heart disease who are not candidates for revascularization, whether due to unsuitable coronary anatomy, excess risk due to age or comorbidities, or simply patient preference? There are also patients who are refractory to treatment with beta-blockers, calcium channel blockers, and long-acting nitrates, despite revascularization.
When revascularization (or re-revascularization) is not an option and patients are experiencing refractory angina, Todd D. Miller, MD, of the Mayo Clinic, Rochester, suggests focusing treatment on quality of life (QOL). Plus, he said, all patients with complex multivessel CAD should be reviewed by a heart team including a cardiac surgeon and interventional cardiologist.
The issue is both important and timely given the increasing prevalence of individuals with multiple chronic conditions, which is already evident in more than one-quarter of adults. According to new ACC/AHA guidelines, in the large population of Medicare beneficiaries, the prevalence of persons with multiple chronic conditions is considerably greater: more than two-thirds (68%) have at least two chronic conditions, and 14% have >6 chronic conditions.1
Current PCI and CABG guidelines include a combined section on revascularization crafted together by the two documents’ writing committees.2,3 The “heart team” approach is a Class I recommendation (the highest level) for patients with unprotected left main or complex CAD, encouraging interventional cardiologists and cardiothoracic surgeons to jointly review the patient’s condition/coronary anatomy, evaluate the pros and cons of treatment options, and then present this information to the patient, along with their recommendations. This collaborative assessment of revascularization options, or the decision to treat with guideline-directed medical therapy without revascularization, is considered “optimal” according to the guidelines.
The guidelines explain that support for using a heart team approach comes from reports that patients with complex CAD referred specifically for PCI or CABG in concurrent trial registries have lower mortality rates than those randomly assigned to PCI or CABG in controlled trials.
When Revascularization Is Not an Option
For ischemic heart disease with refractory angina that cannot be revascularized, Dr. Miller said options include optimizing medical therapy, such as beta-blockers, calcium channel blockers, nitrates, ranolazine, allopurinol, L-arginine, opioids, and perhaps some investigational agents (if you can get the patient enrolled in a clinical trial). In this setting, the heart team may include the patient’s general cardiologist, primary doctor, family, nurses, and perhaps other office staff.
While the medical record may suggest the patient is on appropriate therapy, adherence may be a factor. After MI, a large proportion of patients discontinue use of medications over time. Indeed, by 3 years, more than half of patients in one community-based study had already stopped taking statins, beta-blockers, or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers.4
Also, it’s important to target risk factors through statin therapy, antihypertensives, antiplatelets, smoking cessation, weight loss, exercise, and therapy targeting depression. The heart team may include additional members, such as an exercise physiologist, psychologist, or psychiatrist.
Exercise may seem like a stretch for some patients with refractory angina, but Dr. Miller pointed to one study of men from a decade ago comparing PCI or a 12-month program of regular physical exercise in selected patients with stable CAD.5 Both approaches were equally effective in reducing angina. Moreover, participants randomized to exercise saw superior event-free survival and exercise capacity at lower costs, notably owing to reduced rehospitalizations and fewer repeat revascularizations.
For refractory angina, some patients may benefit from neurological options, such as spinal cord stimulation, sympathectomy, or subcutaneous electrical nerve stimulation, enlarging the team to obtain input from pain clinic members, an anesthesiologist, or neurosurgeon.
Finally, the management of patients with refractory angina who are unsuitable for further revascularization is strikingly different across the world, and contingent on local resources and available expertise. A recent review looked at new emerging treatment principles, such as metabolic modulation, therapeutic angiogenesis, and novel interventional techniques (coronary in-flow redistribution and approaches to chronic total occlusion).6
The contemporary management of refractory angina encourages individualized, patient-centered care in interdisciplinary, specialized clinics. Indeed, at ACC.14, Henry et al. reported that patients attending a refractory angina clinic who rated their health as good or excellent more than doubled from baseline to 1 year (15.8% vs. 42.2%; p < 0.001). Similarly, their QOL score was significantly improved at 1 year compared to baseline (p = 0.025) as was angina stability (p = 0.017) and angina frequency (p = 0.010).
- Arnett DK, Goodman RA, Halperin JL, et al. J Am Coll Cardiol. 2014;64:1851-6.
- Levine GN, Bates ER, Blankenship JC, et al. J Am Coll Cardiol. 2011;58:e44-e122.
- Hillis L, Smith PK, Anderson JL, et al. J Am Coll Cardiol. 2011;58:e123-e210.
- Shah ND, Dunlay SM, Ting HH, et al. Am J Med. 2009;122:961.e7-13.
- Hambrecht R, Walther C, Möbius-Winkler S, et al. Circulation. 2004;109:1371-8.
- Henry TD, Satran D, Jolicoeur EM. Nat Rev Cardiol. 2014;11:78-95.
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