Advertisement

Extracorporeal shockwave myocardial revascularization therapy in refractory angina patients

      Refractory angina represents the real new challenge for clinical cardiologists. Despite all the interventional and medical progress, it is not uncommon to feel disarmed facing highly symptomatic patients already on top of medical therapy, not eligible for further revascularization. The increased prevalence of the disease, also because of the raised life expectancy and comorbidities in general which might constrain the indication to revascularization (i.e., advanced kidney disease, contraindication to dual antiplatelet therapy), will lead to the need of refractory angina dedicated outpatients' clinics. However, despite the clear target of reducing symptoms, how to achieve it is still unclear and tricky. In a recent study published on this journal, the role of an intensive specialized medical treatment was associated to a significant symptom improvement in patients initially diagnosed with refractory angina [
      • Dourado L.O.
      • Poppi N.T.
      • Adam E.L.
      • et al.
      The effectiveness of intensive medical treatment in patients initially diagnosed with refractory angina.
      ]. Can this be enough? Indeed, new tools and new approaches need to be evaluated. The recently published COSIRA trial demonstrated the efficacy of the Reducer implanted in the coronary sinus in improving the quality of life and symptoms in a small cohort of patients [
      • Verheye S.
      • Jolicœur E.M.
      • Behan M.W.
      • Pettersson T.
      • Sainsbury P.
      • Hill J.
      • Vrolix M.
      • Agostoni P.
      • Engstrom T.
      • Labinaz M.
      • de Silva R.
      • Schwartz M.
      • Meyten N.
      • Uren N.G.
      • Doucet S.
      • Tanguay J.F.
      • Lindsay S.
      • Henry T.D.
      • White C.J.
      • Edelman E.R.
      • Banai S.
      Efficacy of a device to narrow the coronary sinus in refractory angina.
      ]. However, we do not have to forget that other tools are nowadays effective, and encouraging data have already been published (i.e., enhanced external counter pulsation). Extracorporeal shockwave myocardial revascularization therapy (ESMR) uses low-intensity shockwaves targeted to the myocardium. This leads to the release of angiogenesis-mediating growth factors (i.e., endothelial nitric oxide synthase and vascular endothelial growth factor) and induces the recruitment of endothelial progenitor cells [
      • Aicher A.
      • Heeschen C.
      • Sasaki K.
      • Urbich C.
      • Zeiher A.H.
      • Dimmeler S.
      Low-energy shock wave for enhancing recruitment of endothelial progenitor cells.
      ]. Several studies already evaluated ESMR in refractory angina patients and they all agree in its efficacy and safety [
      • Schmid J.P.
      • Capoferri M.
      • Wahl A.
      • Eshtehardi P.
      • Hess O.M.
      Cardiac shock wave therapy for chronic refractory angina pectoris. A prospective placebo-controlled randomized trial.
      ,
      • Alunni G.
      • Marra S.
      • Meynet I.
      • D'amico M.
      • Elisa P.
      • Fanelli A.
      • Molinaro S.
      • Garrone P.
      • Deberardinis A.
      • Campana M.
      • Lerman A.
      The beneficial effect of extracorporeal shockwave myocardial revascularization in patients with refractory angina.
      ,
      • Zuoziene G.
      • Leibowitz D.
      • Celutkiene J.
      • Burneikaite G.
      • Ivaskeviciene L.
      • Kalinauskas G.
      • Maneikiene V.V.
      • Palionis D.
      • Janusauskas V.
      • Valeviciene N.
      • Laucevicius A.
      Multimodality imaging of myocardial revascularization using cardiac shock wave therapy.
      ]. Patients refer a marked symptom improvement and a decreased nitrate intake after the treatment. Left ventricle ejection fraction as assessed by cardiac MRI significantly improved too, as reported in a recent study [
      • Zuoziene G.
      • Leibowitz D.
      • Celutkiene J.
      • Burneikaite G.
      • Ivaskeviciene L.
      • Kalinauskas G.
      • Maneikiene V.V.
      • Palionis D.
      • Janusauskas V.
      • Valeviciene N.
      • Laucevicius A.
      Multimodality imaging of myocardial revascularization using cardiac shock wave therapy.
      ]. Moreover, ESMR therapy reduces hospitalization in a patient with refractory angina [
      • Alunni G.
      • Marra S.
      • Meynet I.
      • D'amico M.
      • Elisa P.
      • Fanelli A.
      • Molinaro S.
      • Garrone P.
      • Deberardinis A.
      • Campana M.
      • Lerman A.
      The beneficial effect of extracorporeal shockwave myocardial revascularization in patients with refractory angina.
      ]. Data collected in our centre confirms that ESMR is both a safe and an efficacious means and needs to be considered in refractory angina patients with documented myocardial inducible ischemia. Improvement in the total Seattle Angina Questionnaire score was seen in 86% of patients, and the nitroglycerin use significantly decreased too (p < 0.001). Exercise tolerance was significantly enhanced by ESMR (p < 0.002) and a mild improvement of myocardial perfusion by SPECT was documented too. ESMR, as already published, does not cause any myocardial damage as no troponin T release was documented during the treatment. No changes of natriuretic peptide were documented before and after the treatment.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to International Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Dourado L.O.
        • Poppi N.T.
        • Adam E.L.
        • et al.
        The effectiveness of intensive medical treatment in patients initially diagnosed with refractory angina.
        Int. J. Cardiol. Mar 17 2015; 186: 29-31
        • Verheye S.
        • Jolicœur E.M.
        • Behan M.W.
        • Pettersson T.
        • Sainsbury P.
        • Hill J.
        • Vrolix M.
        • Agostoni P.
        • Engstrom T.
        • Labinaz M.
        • de Silva R.
        • Schwartz M.
        • Meyten N.
        • Uren N.G.
        • Doucet S.
        • Tanguay J.F.
        • Lindsay S.
        • Henry T.D.
        • White C.J.
        • Edelman E.R.
        • Banai S.
        Efficacy of a device to narrow the coronary sinus in refractory angina.
        N. Engl. J. Med. 2015; 372: 519-527
        • Aicher A.
        • Heeschen C.
        • Sasaki K.
        • Urbich C.
        • Zeiher A.H.
        • Dimmeler S.
        Low-energy shock wave for enhancing recruitment of endothelial progenitor cells.
        Circulation. 2006; : 2823-2830
        • Schmid J.P.
        • Capoferri M.
        • Wahl A.
        • Eshtehardi P.
        • Hess O.M.
        Cardiac shock wave therapy for chronic refractory angina pectoris. A prospective placebo-controlled randomized trial.
        Cardiovasc. Ther. 2013; 313: e1-e6
        • Alunni G.
        • Marra S.
        • Meynet I.
        • D'amico M.
        • Elisa P.
        • Fanelli A.
        • Molinaro S.
        • Garrone P.
        • Deberardinis A.
        • Campana M.
        • Lerman A.
        The beneficial effect of extracorporeal shockwave myocardial revascularization in patients with refractory angina.
        Cardiovasc. Revasc. Med. 2015; 16: 6-11
        • Zuoziene G.
        • Leibowitz D.
        • Celutkiene J.
        • Burneikaite G.
        • Ivaskeviciene L.
        • Kalinauskas G.
        • Maneikiene V.V.
        • Palionis D.
        • Janusauskas V.
        • Valeviciene N.
        • Laucevicius A.
        Multimodality imaging of myocardial revascularization using cardiac shock wave therapy.
        Int. J. Cardiol. 2015; 187: 229-230