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Published in: BMC Cardiovascular Disorders 1/2009

Open Access 01-12-2009 | Research article

Spinal cord stimulation in the treatment of refractory angina: systematic review and meta-analysis of randomised controlled trials

Authors: Rod S Taylor, Jessica De Vries, Eric Buchser, Mike JL DeJongste

Published in: BMC Cardiovascular Disorders | Issue 1/2009

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Abstract

Background

The aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina.

Methods

We searched a number of electronic databases including Medline, Embase and Cochrane Library up to February 2008 to identify randomised controlled trials (RCTs) reporting exercise capacity, ischemic burden, functional class, quality of life, usage of anti-anginal medication, costs and adverse events including mortality. Results were reported both descriptively for each study and using random effects meta-analysis. Given the variety in outcomes reported, some outcome results were pooled as standardised mean differences (SMD) and reported in standard deviation units.

Results

Seven RCTs were identified in a total of 270 refractory angina patients. The outcomes of SCS were found to be similar when directly compared to coronary artery bypass grafting (CABG) and percutaneous myocardial laser revascularisation (PMR). Compared to a 'no stimulation' control, there was some evidence of improvement in all outcomes following SCS implantation with significant gains observed in pooled exercise capacity (SMD: 0.76, 0.07 to 1.46, p = 0.03) and health-related quality of life (SMD: 0.83, 95% CI: 0.32 to 1.34, p = 0.001). Trials were small and were judged to range considerably in their quality. The healthcare costs of SCS appeared to be lower than CABG at 2-years follow up.

Conclusion

SCS appears to be an effective and safe treatment option in the management of refractory angina patients and of similar efficacy and safety to PMR, a potential alternative treatment. Further high quality RCT and cost effectiveness evidence is needed before SCS can be accepted as a routine treatment for refractory angina.
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Literature
1.
go back to reference Mannheimer C, Camici P, Chester MR, Collins A, DeJongste M, Eliasson T, Follath F, Hellemans I, Herlitz J, Lüscher T, Pasic M, Thelle D: The problem of chronic refractory angina; report from the ESC Joint Study Group on the Treatment of Refractory Angina. Eur Heart J. 2002, 23: 355-70. 10.1053/euhj.2001.2706.CrossRefPubMed Mannheimer C, Camici P, Chester MR, Collins A, DeJongste M, Eliasson T, Follath F, Hellemans I, Herlitz J, Lüscher T, Pasic M, Thelle D: The problem of chronic refractory angina; report from the ESC Joint Study Group on the Treatment of Refractory Angina. Eur Heart J. 2002, 23: 355-70. 10.1053/euhj.2001.2706.CrossRefPubMed
2.
go back to reference Mukherjee D, Bhatt DL, Roe MT, Patel V, Ellis SG: Direct myocardial revascularization and angiogenesis – how many patients might be eligible?. Am J Cardiol. 1999, 84: 598-60. 10.1016/S0002-9149(99)00387-2.CrossRefPubMed Mukherjee D, Bhatt DL, Roe MT, Patel V, Ellis SG: Direct myocardial revascularization and angiogenesis – how many patients might be eligible?. Am J Cardiol. 1999, 84: 598-60. 10.1016/S0002-9149(99)00387-2.CrossRefPubMed
3.
go back to reference Svorkdal N: Treatment of inoperable coronary disease and refractory angina: spinal stimulators, epidurals, gene therapy, transmyocardial laser, and counterpulsation. Semin Cardiothorac Vasc Anesth. 2004, 8: 43-58. 10.1177/108925320400800109.CrossRefPubMed Svorkdal N: Treatment of inoperable coronary disease and refractory angina: spinal stimulators, epidurals, gene therapy, transmyocardial laser, and counterpulsation. Semin Cardiothorac Vasc Anesth. 2004, 8: 43-58. 10.1177/108925320400800109.CrossRefPubMed
4.
go back to reference Murphy DF, Giles KE: Dorsal column stimulation for pain relief from intractable angina pectoris. Pain. 1987, 28: 365-8. 10.1016/0304-3959(87)90070-4.CrossRefPubMed Murphy DF, Giles KE: Dorsal column stimulation for pain relief from intractable angina pectoris. Pain. 1987, 28: 365-8. 10.1016/0304-3959(87)90070-4.CrossRefPubMed
5.
go back to reference Ubbink DT, Vermeulen H: Spinal Cord Stimulation for Critical Leg Ischemia: A Review of Effectiveness & Optimal Patient Selection. J Pain Symptom Manage. 2006, 31 (4 Suppl): S30-5. 10.1016/j.jpainsymman.2005.12.013.CrossRefPubMed Ubbink DT, Vermeulen H: Spinal Cord Stimulation for Critical Leg Ischemia: A Review of Effectiveness & Optimal Patient Selection. J Pain Symptom Manage. 2006, 31 (4 Suppl): S30-5. 10.1016/j.jpainsymman.2005.12.013.CrossRefPubMed
6.
go back to reference Kemler MA, Barendse GA, van Kleef M, de Vet HC, Rijks CP, Furnee CA, Wildenberg van den FA: Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med. 2000, 348: 618-624. 10.1056/NEJM200008313430904.CrossRef Kemler MA, Barendse GA, van Kleef M, de Vet HC, Rijks CP, Furnee CA, Wildenberg van den FA: Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med. 2000, 348: 618-624. 10.1056/NEJM200008313430904.CrossRef
7.
go back to reference Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Moletf J, Thomson S, O'Callaghan J, Eisenberg E, Milbouw G, Buchser E, Fortini G, Richardson G, North RB: Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. ISRCTN 77527324. Pain. 2007, 132: 179-88. 10.1016/j.pain.2007.07.028.CrossRefPubMed Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Moletf J, Thomson S, O'Callaghan J, Eisenberg E, Milbouw G, Buchser E, Fortini G, Richardson G, North RB: Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. ISRCTN 77527324. Pain. 2007, 132: 179-88. 10.1016/j.pain.2007.07.028.CrossRefPubMed
8.
go back to reference Satran D, Traverse JH, Barsness GW, Lerman A, Simari RD, Poulose AK, Johnson RK, Henry TD: Emerging therapies for refractory angina. Minn Med. 2008, 91: 36-9.PubMed Satran D, Traverse JH, Barsness GW, Lerman A, Simari RD, Poulose AK, Johnson RK, Henry TD: Emerging therapies for refractory angina. Minn Med. 2008, 91: 36-9.PubMed
9.
go back to reference De Vries J, Foreman RD, DeJongste MJ: The anti-ischemic effects of electrical neurostimulation in the heart. Cleve Clin J Med. 2007, 74 (Suppl 1): S42-7.CrossRefPubMed De Vries J, Foreman RD, DeJongste MJ: The anti-ischemic effects of electrical neurostimulation in the heart. Cleve Clin J Med. 2007, 74 (Suppl 1): S42-7.CrossRefPubMed
10.
go back to reference Buchser E, Durrer A, Albrecht E: Spinal cord stimulation for the management of refractory angina pectoris. J Pain Symptom Manage. 2006, 31 (4 Suppl): S36-42. 10.1016/j.jpainsymman.2005.12.008.CrossRefPubMed Buchser E, Durrer A, Albrecht E: Spinal cord stimulation for the management of refractory angina pectoris. J Pain Symptom Manage. 2006, 31 (4 Suppl): S36-42. 10.1016/j.jpainsymman.2005.12.008.CrossRefPubMed
11.
go back to reference Augustinsson LE: Spinal cord stimulation in peripheral vascular disease and angina pectoris. J Neurosurg Sci. 2003, 47: 37-40.PubMed Augustinsson LE: Spinal cord stimulation in peripheral vascular disease and angina pectoris. J Neurosurg Sci. 2003, 47: 37-40.PubMed
13.
go back to reference Fraker TD, Fihn SD, 2002 Chronic Stable Angina Writing Committee; American College of Cardiology; American Heart Association, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB, Gardin JM, O'Rourke RA, Williams SV, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW: 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol. 2007, 50: 2264-74. 10.1016/j.jacc.2007.08.002.CrossRefPubMed Fraker TD, Fihn SD, 2002 Chronic Stable Angina Writing Committee; American College of Cardiology; American Heart Association, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB, Gardin JM, O'Rourke RA, Williams SV, Smith SC, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW: 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol. 2007, 50: 2264-74. 10.1016/j.jacc.2007.08.002.CrossRefPubMed
15.
go back to reference Jadad AR, Cook DJ, Jones A, Klassen TP, Tugwell P, Moher M, Moher D: Methodology and reports of systematic reviews and meta-analyses: a comparison of Cochrane reviews with articles published in paper-based journals. JAMA. 1998, 280: 278-80. 10.1001/jama.280.3.278.CrossRefPubMed Jadad AR, Cook DJ, Jones A, Klassen TP, Tugwell P, Moher M, Moher D: Methodology and reports of systematic reviews and meta-analyses: a comparison of Cochrane reviews with articles published in paper-based journals. JAMA. 1998, 280: 278-80. 10.1001/jama.280.3.278.CrossRefPubMed
16.
go back to reference Follmann D, Elliot P, Suh I, Cutler J: Variance imputation for overviews of clinical trials with continuous response. J Clin Epidemiol. 1992, 45: 769-773. 10.1016/0895-4356(92)90054-Q.CrossRefPubMed Follmann D, Elliot P, Suh I, Cutler J: Variance imputation for overviews of clinical trials with continuous response. J Clin Epidemiol. 1992, 45: 769-773. 10.1016/0895-4356(92)90054-Q.CrossRefPubMed
17.
go back to reference DerSimonsen R, Laird N: Meta analysis in clinical trials. Control Clin Trials. 1986, 7: 177-188. 10.1016/0197-2456(86)90046-2.CrossRef DerSimonsen R, Laird N: Meta analysis in clinical trials. Control Clin Trials. 1986, 7: 177-188. 10.1016/0197-2456(86)90046-2.CrossRef
19.
go back to reference Mannheimer C, Eliasson T, Augustinsson LE, Blomstrand C, Emanuelsson H, Larsson S, Norrsell H, Hjalmarsson A: Electrical stimulation versus coronary artery bypass surgery in severe angina pectoris: the ESBY study. Circulation. 1998, 97: 1157-63.CrossRefPubMed Mannheimer C, Eliasson T, Augustinsson LE, Blomstrand C, Emanuelsson H, Larsson S, Norrsell H, Hjalmarsson A: Electrical stimulation versus coronary artery bypass surgery in severe angina pectoris: the ESBY study. Circulation. 1998, 97: 1157-63.CrossRefPubMed
20.
go back to reference Andrell P, Ekre O, Eliasson T, Blomstrand C, Börjesson M, Nilsson M, Mannheimer C: Cost-effectiveness of spinal cord stimulation versus coronary artery bypass grafting in patients with severe angina pectoris – long-term results from the ESBY study. Cardiology. 2003, 99: 20-4. 10.1159/000068447.CrossRefPubMed Andrell P, Ekre O, Eliasson T, Blomstrand C, Börjesson M, Nilsson M, Mannheimer C: Cost-effectiveness of spinal cord stimulation versus coronary artery bypass grafting in patients with severe angina pectoris – long-term results from the ESBY study. Cardiology. 2003, 99: 20-4. 10.1159/000068447.CrossRefPubMed
21.
go back to reference Ekre O, Eliasson T, Norrsell H, Währborg P, Mannheimer C: Electrical Stimulation versus Coronary Artery Bypass Surgery in Severe Angina Pectoris. Long-term effects of spinal cord stimulation and coronary artery bypass grafting on quality of life and survival in the ESBY study. Eur Heart J. 2002, 23: 1938-45. 10.1053/euhj.2002.3286.CrossRefPubMed Ekre O, Eliasson T, Norrsell H, Währborg P, Mannheimer C: Electrical Stimulation versus Coronary Artery Bypass Surgery in Severe Angina Pectoris. Long-term effects of spinal cord stimulation and coronary artery bypass grafting on quality of life and survival in the ESBY study. Eur Heart J. 2002, 23: 1938-45. 10.1053/euhj.2002.3286.CrossRefPubMed
22.
go back to reference Norrsell H, Pilhall M, Eliasson T, Mannheimer C: Effects of spinal cord stimulation and coronary artery bypass grafting on myocardial ischemia and heart rate variability: further results from the ESBY study. Cardiology. 2000, 94: 12-18. 10.1159/000007040.CrossRefPubMed Norrsell H, Pilhall M, Eliasson T, Mannheimer C: Effects of spinal cord stimulation and coronary artery bypass grafting on myocardial ischemia and heart rate variability: further results from the ESBY study. Cardiology. 2000, 94: 12-18. 10.1159/000007040.CrossRefPubMed
23.
go back to reference McNab D, Khan SN, Sharples LD, Ryan JY, Freeman C, Caine N, Tait S, Hardy I, Schofield PM: An open label, single-centre, randomized trial of spinal cord stimulation vs. percutaneous myocardial laser revascularization in patients with refractory angina pectoris: the SPiRiT trial. Eur Heart J. 2006, 27: 1048-53. 10.1093/eurheartj/ehi827.CrossRefPubMed McNab D, Khan SN, Sharples LD, Ryan JY, Freeman C, Caine N, Tait S, Hardy I, Schofield PM: An open label, single-centre, randomized trial of spinal cord stimulation vs. percutaneous myocardial laser revascularization in patients with refractory angina pectoris: the SPiRiT trial. Eur Heart J. 2006, 27: 1048-53. 10.1093/eurheartj/ehi827.CrossRefPubMed
24.
go back to reference De Jongste MJ, Staal MJ: Preliminary results of a randomized study on the clinical efficacy of spinal cord stimulation for refractory severe angina pectoris. Acta Neurochir Suppl. (Wien). 1993, 58: 161-4. De Jongste MJ, Staal MJ: Preliminary results of a randomized study on the clinical efficacy of spinal cord stimulation for refractory severe angina pectoris. Acta Neurochir Suppl. (Wien). 1993, 58: 161-4.
25.
go back to reference De Jongste MJ, Hautvast RW, Hillege HL, Lie KI: Efficacy of spinal cord stimulation as adjuvant therapy for intractable angina pectoris: a prospective, randomized clinical study. Working Group on Neurocardiology. J Am Coll Cardiol. 1994, 23: 1592-7.CrossRefPubMed De Jongste MJ, Hautvast RW, Hillege HL, Lie KI: Efficacy of spinal cord stimulation as adjuvant therapy for intractable angina pectoris: a prospective, randomized clinical study. Working Group on Neurocardiology. J Am Coll Cardiol. 1994, 23: 1592-7.CrossRefPubMed
26.
go back to reference Di Pede F, Zuin G, Giada F, Pinato G, Turiano G, Bevilacqua M, Cazzin R, Raviele A: Long-term effects of spinal cord stimulation on myocardial ischemia and heart rate variability: results of a 48-hour ambulatory electrocardiographic monitoring. Ital Heart J. 2001, 2: 690-5.PubMed Di Pede F, Zuin G, Giada F, Pinato G, Turiano G, Bevilacqua M, Cazzin R, Raviele A: Long-term effects of spinal cord stimulation on myocardial ischemia and heart rate variability: results of a 48-hour ambulatory electrocardiographic monitoring. Ital Heart J. 2001, 2: 690-5.PubMed
27.
go back to reference Hautvast RW, De Jongste MJ, Staal MJ, van Gilst WH, Lie KI: Spinal cord stimulation in chronic intractable angina pectoris: a randomized, controlled efficacy study. Am Heart J. 1998, 136: 1114-20. 10.1016/S0002-8703(98)70171-1.CrossRefPubMed Hautvast RW, De Jongste MJ, Staal MJ, van Gilst WH, Lie KI: Spinal cord stimulation in chronic intractable angina pectoris: a randomized, controlled efficacy study. Am Heart J. 1998, 136: 1114-20. 10.1016/S0002-8703(98)70171-1.CrossRefPubMed
28.
go back to reference Jessurun GA, De Jongste MJ, Hautvast RW, Tio RA, Brouwer J, van Lelieveld S, Crijns HJ: Clinical follow-up after cessation of chronic electrical neuromodulation in patients with severe coronary artery disease: a prospective randomized controlled study on putative involvement of sympathetic activity. Pacing Clin Electrophysiol. 1999, 22: 1432-9. 10.1111/j.1540-8159.1999.tb00346.x.CrossRefPubMed Jessurun GA, De Jongste MJ, Hautvast RW, Tio RA, Brouwer J, van Lelieveld S, Crijns HJ: Clinical follow-up after cessation of chronic electrical neuromodulation in patients with severe coronary artery disease: a prospective randomized controlled study on putative involvement of sympathetic activity. Pacing Clin Electrophysiol. 1999, 22: 1432-9. 10.1111/j.1540-8159.1999.tb00346.x.CrossRefPubMed
29.
go back to reference Eddicks S, Maier-Hauff K, Schenk M, Müller A, Baumann G, Theres H: Thoracic spinal cord stimulation improves functional status and relieves symptoms in patients with refractory angina pectoris: the first placebo-controlled randomised study. Heart. 2007, 93: 585-90. 10.1136/hrt.2006.100784.CrossRefPubMedPubMedCentral Eddicks S, Maier-Hauff K, Schenk M, Müller A, Baumann G, Theres H: Thoracic spinal cord stimulation improves functional status and relieves symptoms in patients with refractory angina pectoris: the first placebo-controlled randomised study. Heart. 2007, 93: 585-90. 10.1136/hrt.2006.100784.CrossRefPubMedPubMedCentral
30.
go back to reference Lanza GA, Sestito A, Sgueglia GA, Infusino F, Papacci F, Visocchi M, Ierardi C, Meglio M, Bellocci F, Crea F: Effect of spinal cord stimulation on spontaneous and stress-induced angina and 'ischemia-like' ST-segment depression in patients with cardiac syndrome X. Eur Heart J. 2005, 26: 983-9. 10.1093/eurheartj/ehi089.CrossRefPubMed Lanza GA, Sestito A, Sgueglia GA, Infusino F, Papacci F, Visocchi M, Ierardi C, Meglio M, Bellocci F, Crea F: Effect of spinal cord stimulation on spontaneous and stress-induced angina and 'ischemia-like' ST-segment depression in patients with cardiac syndrome X. Eur Heart J. 2005, 26: 983-9. 10.1093/eurheartj/ehi089.CrossRefPubMed
31.
go back to reference Wu M, Linderoth B, Foreman RD: Putative mechanisms behind effects of spinal cord stimulation on vascular diseases: A review of experimental studies. Auton Neurosci. 2008, 138: 9-23. 10.1016/j.autneu.2007.11.001.CrossRefPubMedPubMedCentral Wu M, Linderoth B, Foreman RD: Putative mechanisms behind effects of spinal cord stimulation on vascular diseases: A review of experimental studies. Auton Neurosci. 2008, 138: 9-23. 10.1016/j.autneu.2007.11.001.CrossRefPubMedPubMedCentral
32.
go back to reference Van Zundert J: Clinical research in interventional pain management techniques: the clinician's point of view. Pain Pract. 2007, 7: 221-9. 10.1111/j.1533-2500.2007.00139.x.CrossRefPubMed Van Zundert J: Clinical research in interventional pain management techniques: the clinician's point of view. Pain Pract. 2007, 7: 221-9. 10.1111/j.1533-2500.2007.00139.x.CrossRefPubMed
33.
go back to reference Dyer MT, Goldsmith KA, Khan SN, Sharples LD, Freeman C, Hardy I, Buxton MJ, Schofield PM: Clinical and cost-effectiveness analysis of an open label, single-centre, randomised trial of spinal cord stimulation (SCS) versus percutaneous myocardial laser revascularisation (PMR) in patients with refractory angina pectoris: The SPiRiT trial. BMC Trials. 2008, 9: 40-10.1186/1745-6215-9-40.CrossRef Dyer MT, Goldsmith KA, Khan SN, Sharples LD, Freeman C, Hardy I, Buxton MJ, Schofield PM: Clinical and cost-effectiveness analysis of an open label, single-centre, randomised trial of spinal cord stimulation (SCS) versus percutaneous myocardial laser revascularisation (PMR) in patients with refractory angina pectoris: The SPiRiT trial. BMC Trials. 2008, 9: 40-10.1186/1745-6215-9-40.CrossRef
Metadata
Title
Spinal cord stimulation in the treatment of refractory angina: systematic review and meta-analysis of randomised controlled trials
Authors
Rod S Taylor
Jessica De Vries
Eric Buchser
Mike JL DeJongste
Publication date
01-12-2009
Publisher
BioMed Central
Published in
BMC Cardiovascular Disorders / Issue 1/2009
Electronic ISSN: 1471-2261
DOI
https://doi.org/10.1186/1471-2261-9-13

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