Chronic stable angina spinal cord stimulation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

In patients with refractory angina, spinal cord stimulation (SCS) is used to provide analgesia in the region of radiation of anginal-pain with the help an implanted device consisting of a stimulating electrode tip that extends into the dorsal epidural space, usually at the C7-T1 level.

Spinal Cord Stimulation

Mechanism of Benefit

Spinal cord stimulation (SCS) induced analgesia is considered to be secondary to:

Neurohormonal Mechanisms

• Decrease in the neurotransmission of painful stimuli
• Increase in the release of endogenous opiates

Anti-Ischemic Effects

• Reduction in the myocardial oxygen consumption secondary to decrease in sympathetic tone or a change in the cardiac metabolism of beta-endorphine.

• Redistribution of myocardial blood flow from non-ischemic to ischemic regions.

Indication

• Spinal cord stimulation is indicated in patients with chronic stable angina refractory to medical therapy, PCI, and/or surgical therapy. However, current finding strongly suggest that more data are still needed and therefore, spinal cord stimulation should be only considered when other treatment options have failed.

Approach

• Under local anesthesia, an implantable device with a stimulating electrode is placed in the spinal cord system, the tip of which extends into the dorsal epidural space, usually at the level of C7-T1.
• The tip is placed in the epidural space so as to produce analgesia in the region of anginal pain radiation.

Success Rate

• Several observational studies have reported success rates of up to 80% in decreasing anginal frequency and severity.

Disadvantages

• Several studies that assessed the relationship between anginal pain and myocardial ischemia using various exercise-induced and/or pharmacological stressors to the heart, found that transcutaneous nerve stimulation did not significantly affect neither the anginal pain or MI.

• Furthermore, anginal relief with spinal cord stimulation did not conceal the evidence of acute myocardial infarction.

Supportive Trial Data

Numerous studies from the early 1980s have published the benefits of transcutaneous nerve stimulation and spinal cord stimulation on myocardial ischemia and angina. The absence of arrhythmia and a significant reduction in the ischemic burden have been demonstrated in a few studies using Holter monitoring.

Spinal cord electrical stimulation provided long-term safety in terms of significant symptomatic improvement, reduction in total number and duration of ischemic episodes as observed at 62-month follow-up. The time of the work during exercise stress test was also significantly prolonged.

Randomized-Control Studies

• Efficacy of spinal cord stimulation, as a treatment for chronic intractable angina, was studied in a small randomized-control study involving 13 patients treated with spinal cord stimulation versus 12 control patients with chronic angina. At 6-week follow-up, in comparison to the control group, the treated group demonstrated significant increase in the exercise duration (P=0.03) and the time to angina (P=0.01); and a significant reduction in the incidence of anginal attacks and sublingual nitrate consumption (P=0.01) and in the incidence of ischemic episodes on 48-hour electrocardiogram (P=0.04). The ST segment depression on the exercise electrocardiogram decreased at comparable workload (P=0.01) with a significant increase in the perceived quality of life (P=0.03). Thus, the study concluded that spinal cord stimulation is an effective alternative the management of chronic intractable angina pectoris, and that its effect was exerted through anti-ischemic action.

• Another small study involved 24 patients with refractory angina off which 12 patients were implanted with a spinal cord stimulator versus 12 in the control group. The efficacy in terms of recurrence of angina, nitroglycerin intake, ischemia, and heart rate variability using 48-hour electrocardiographic monitoring were assessed at 4-weeks and 8-weeks. In addition, neurohormonal status and symptom-limited aerobic capacity were also evaluated. The study reported no significant increase in the incidence of anginal complaints or ischemia after withholding stimulation. Neurohormonal levels and aerobic capacity were not altered. Thus, the study concluded that there was no adverse clinical rebound phenomenon after withholding neurostimulation in patients with refractory angina pectoris.

• A randomized controlled study involved 104 patients, with symptomatic indication only for bypass surgery and with an increased surgical risk of complications, who were randomized to either spinal cord stimulation (n=53) or CABG (51). The goal of the study was to compare whether SCS can be used as an alternative to CABG in patients with no proven prognostic benefit from CABG. At 6-month follow-up, both groups demonstrated a highly significant reduction in anginal attacks and consumption of short-acting nitroglycerin without any difference between the groups. The CABG group had an increase in exercise capacity (P=0.02) and less ST segment depression on maximum exercise (P=0.005) which could not be observed in the spinal cord stimulation group. However, the spinal cord stimulation patients did not have active treatment during exercise. Eight deaths occurred during the follow-up period, 7 in the CABG group and 1 in the SCS group. On an intention-to-treat basis, the mortality rate and cerebrovascular morbidity rate was significantly lower in the SCS group (P=0.02 and 0.03 respectively). Thus, the study concluded that CABG and SCS appear to be equivalent methods in terms of symptom relief in this group of patients.

• Another recent study showed that both the CABG and the SCS groups, offered significant increase in the quality of life after 6-months and this beneficial effect remained unchanged after 3 years. There was no difference in mortality between the CABG and spinal cord stimulation groups after 3 and 5 years, respectively. Hence, both methods could be considered as an effective treatment strategy for patients with severe angina, increased surgical risks and estimated to have no prognostic benefits from coronary artery bypass grafting.

Retrospective Studies

Three retrospective studies, that assessed the efficacy of spinal cord stimulation in the management of refractory angina, reported an improvement observed with the chronic use of neurostimulation. However, the predictors of clinical outcomes were related to the traditional CAD risk factors and the mortality rate of patients with refractory angina treated with spinal cord stimulation were found to be similar to that of patients with chronic stable coronary artery disease.

Prospective Study

One prospective study, that evaluated the effect of spinal cord stimulation (SCS) on regional myocardial perfusion as assessed by positron emission tomography, reported a SCS-induced improvement in the exercise-induced angina and electrocardiographic signs of ischemia. However, the observed influence did not appear to be mediated by the changes in regional myocardial perfusion.

Cohort Studies

Four cohort studies, that evaluated the effect of spinal cord stimulation in the management of refractory angina, reported significant relief of anginal symptoms and an improvement in exercise tolerance secondary to the reduction in myocardial ischemia. Thus, these studies concluded the use of SCS as an effective adjuvant therapy for intractable angina, despite a relatively disadvantage of frequent electrode dislocation.

ACC/AHA Guidelines- Spinal Cord Stimulation (DO NOT EDIT)

Class IIb

"1. Spinal cord stimulation (SCS). (Level of Evidence: B)"