Spinal Cord Stimulation for Refractory Angina Pectoris [Neurosurgery Wiki]

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====== Spinal Cord Stimulation for Refractory Angina Pectoris ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/165yO28ehHLcXJajWZ_UInDkSeR3rybXdI_ak54UpND_rNzAlG/?limit=15&utm_campaign=pubmed-2&fc=20250124180624}}
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[[Spinal cord stimulation]] (SCS) has emerged as a promising therapeutic option for managing Refractory [[Angina Pectoris]], offering significant symptom relief and improved quality of life. 


===== Mechanism of Action =====

The proposed mechanisms for SCS in RAP include:

1. **[[Neuromodulation]]**: Alters pain perception by inhibiting nociceptive transmission in the spinal cord.

2. **[[Ischemic Preconditioning]]**: Improves microvascular [[blood flow]] and myocardial [[oxygen]] balance, potentially reducing ischemic episodes.

3. **[[Autonomic Regulation]]**: Enhances parasympathetic [[activity]] and reduces sympathetic tone, which can improve coronary [[perfusion]].

===== Indications =====

SCS is indicated for patients with RAP who meet the following criteria:

- Persistent angina despite optimal pharmacological [[therapy]], including [[nitrate]]s, [[beta blocker]]s, [[calcium channel blocker]]s, and [[antiplatelet]] agents.

- Unsuitability for further [[revascularization]] (e.g., coronary artery bypass grafting or percutaneous coronary intervention).

- Severe impairment of [[quality of life]] due to angina symptoms.

===== Procedure =====

1. **Trial Period**: A temporary [[electrode]] is implanted to assess the efficacy of SCS. This trial lasts 3–7 days.

2. **Permanent Implantation**: If the trial is successful (≥50% reduction in [[angina]] or improvement in quality of life), a permanent electrode and [[pulse generator]] are implanted.

===== Clinical Evidence =====

Studies and meta-analyses have demonstrated the benefits of SCS for RAP:

- **Reduction in Angina Episodes**: SCS significantly reduces the frequency and severity of angina attacks.

- **Improvement in Exercise Tolerance**: Patients exhibit increased capacity to perform physical activities.

- **Enhanced Quality of Life**: SCS is associated with reduced hospital admissions and improved psychological well-being.

- **Safety Profile**: SCS has a favorable safety profile, with most complications being related to device implantation (e.g., infection, lead migration).

===== Benefits =====

- Reduces reliance on high-dose opioids and other analgesics.
- Non-pharmacological and reversible.
- Provides symptomatic relief in a condition with limited treatment options.

===== Challenges and Considerations =====

- High initial cost of implantation.
- Requirement for regular follow-ups and device maintenance.
- Risk of complications such as infection, lead displacement, or inadequate pain relief.


===== Narrative reviews =====

Gazzeri et al. from San Giovanni-Addolorata Hospital, La Sapienza University of Rome, and [[Virgen de la Arrixaca University Clinical Hospital]] in a systematic [[literature review]] evaluated the clinical [[effectiveness]], [[mechanism of action]], and [[safety]] profile of [[Spinal Cord Stimulation for Refractory Angina Pectoris]]. [[Comprehensive]] [[search]]es were performed in [[PubMed]], [[Scopus]], and [[Web of Science]] for studies published between [[1990]] and [[2023]]. Of 328 [[article]]s identified, 6 met the [[inclusion]] and [[exclusion criteria]] for final [[analysis]]. The included studies consistently demonstrated that SCS significantly reduces the frequency of [[angina]]l episodes and [[nitroglycerin]] use while improving [[exercise]] capacity and [[quality of life]]. Proposed mechanisms include modulation of pain signals via the [[gate control theory]], enhancement of autonomic balance, and redistribution of myocardial [[perfusion]]. Novel [[stimulation]] modalities, including high-frequency, [[Burst]], and [[Differential Target Multiplexed]] (DTM), show potential advantages in enhancing patient [[comfort]] and [[clinical outcome]]s.
Nevertheless, long-term studies are necessary to validate these findings and establish the [[comparative efficacy]] of these advanced technologies. SCS is a safe and effective therapy for patients with RAP who are unsuitable for surgical interventions. [[Innovation]]s in [[neurostimulation]], including closed-loop systems and personalized treatment strategies have the potential to optimize outcomes further. Rigorous [[clinical trial]]s are needed to consolidate the role of SCS as a cornerstone therapy for the management of RAP
((Gazzeri R, Mosca J, Occhigrossi F, Mercieri M, Galarza M, Leoni MLG. [[Spinal Cord Stimulation for Refractory Angina Pectoris]]: Current Status and Future Perspectives, a Narrative Review. J Cardiovasc Dev Dis. 2025 Jan 20;12(1):33. doi: 10.3390/jcdd12010033. PMID: 39852311.)).
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The review by Gazzeri et al. is an important contribution to understanding spinal cord stimulation for refractory angina pectoris, particularly in terms of summarizing clinical efficacy and future directions. However, limitations in methodology, sample size, and comparative analysis diminish its impact. Addressing these gaps through a more systematic approach and detailed exploration of long-term outcomes and emerging technologies would enhance the study's utility for clinicians and researchers.

===== Case reports =====
A 48-year-old male patient with recurrent pericarditis, characterized by refractory angina-like pain and reduced left ventricular ejection fraction (LVEF). After 1 year of having a spinal cord stimulator implanted, the patient is free from pain and narcotics, with a reduction of 428 mg equivalent dose of morphine. The patient's LVEF increased from 40% to 45% without changes to his previous medical treatment. This is the first reported case of refractory pericarditis managed with spinal cord stimulation.

Recognizing improved pain management reduced narcotic usage, and improved LVEF in the patient following SCS is critical to paving the way toward a complete understanding of the mechanism of action of SCS. This case reveals the therapeutic potential of SCS for cardiovascular pathologies other than refractory angina pectoris
((Elsliger S, Saucier J, Schneider A, El Helou A. Spinal cord stimulation for refractory pericarditis: a case report and a review of the mechanism of action. Front Pain Res (Lausanne). 2023 Jul 5;4:1174044. doi: 10.3389/fpain.2023.1174044. PMID: 37476333; PMCID: PMC10354338.))