Medullary neurostimulation in refractory angina

A growing number of patients present a clinical picture of refractory angina despite major advances in the pharmacological treatment of angina pectoris and myocardial reperfusion techniques. According to the European Society of Cardiology guidelines, refractory angina is a chronic pathology characterized by myocardial ischemia due to coronary artery disease that cannot be controlled by a combination of maximum tolerated drug treatment, angioplasty, and coronary revascularization surgery. To determine that a patient is not a candidate for revascularization, it has to be ruled out on the basis of a recent coronary angiogram, and the patient must be receiving the maximum tolerated doses of medical treatment. There must also be proof of reversible ischemia, and other non-coronary causes of chest pain must be ruled out. If all of the above does not resolve, then angina transcutaneous electrical nerve stimulation (TENS) or medullary electricostimulation (MES) should be considered. There are basically two mechanisms responsible for this clinical improvement: modification (not eradication) of pain perception, and its anti-ischemic properties in the myocardium. In this review, we describe our experience and we discuss the long-term symptomatic improvement and lower the functional category obtained with TENS or MES in patients with refractory angina.