Chronic Refractory Angina (CRA) - Role of interventional pain management

<p>Rubina Ahmad</p>

Chronic Refractory Angina (CRA) - Role of interventional pain management

Rubina Ahmad

North Devon District Hospital NHS Trust, UK

: Analg Resusc: Curr Res

Abstract

Refractory Angina Pectoris (RA) is a debilitating clinical diagnosis and is described as myocardial ischemia-related chronic pain syndrome and is a major clinical problem where patients seem unresponsive to primary, secondary and tertiary conventional treatments of maximal anti-anginal medication, angioplasty or coronary bypass surgery (CABG). Chronic Refractory Angina (CRA) symptoms may produce great functional disability, fear & anxiety of the unknown, depression, sleep deprivation and alteration of mood. The concept of treating the symptoms of cardiovascular chest pain by interrupting the sympathetic pathways was first proposed by Frank 1899. Evidence suggests that repeated sympathetic blockade (SGB) for relief of RA improves pain scores and prevents these patients from repeated hospital and primary care visits including reducing intensity of angina for a considerable time period – sometimes up to several months. However, patients are extensively educated and treatment of SGB is offered as part of the comprehensive treatment approach. Most patients also manage to reduce intake of analgesics including opiates that helps them remain more alert and interested in life with improved quality of life (QoL). Speculative suggestion is that by interrupting the link in this sympathetic loop, a prolonged effect on the pain can be obtained with repeated sympathetic blocks, but the duration of benefit after successive blocks is unpredictable. Spinal Cord Stimulation is another option for long term management of chronic refractory angina pain where inserting a stimulating electrode into the thoracic epidural space under local anaesthetic is helpful in managing persistent angina. The final position of the electrode being determined by the patient’s sensation of paraesthesia induced by the neuro stimulator in the area where the angina pain is usually felt. The indicated evidence suggests “C” possibly due to paucity of literature. Also defining outcomes regarding treatment modalities is difficult in this population because of the heterogeneous spectrum of patients. However temporary sympathectomy has proved to be effective in a vast majority of CRA patients.