“No option” for revascularisation in refractory angina does not mean never

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Tim Henry

Data from OPTIMIST (Options in myocardial ischemic syndrome therapy) registry indicate that a quarter (25%) of patients with refractory angina who are initially deemed to be “no option” for revascularisation will go on to have such an intervention. Furthermore, mortality in these patients is significantly lower than that for patients who do not go on to have revascularisation.

Writing in Catheterizations and Cardiovascular Interventions, Rahul Sharma, Tim Henry, (Cedars Sinai Heart Institute, Los Angeles, USA and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, USA) and others report that patients with refractory angina—persistent or recurrent symptoms that cannot be controlled by a combination of medical therapy and revascularisation—are labelled as “no option” if revascularisation with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) does not appear to be feasible. They add that only “limiting and conflicting” data are available for further revascularisation in such patients, noting that one study showed that 61.8% (of 34 patients) of refractory angina underwent revascularisation within nine months of being categorised as “no option” whereas another study showed that only 15.5% (of 200) underwent revascularisation within one year.  “We report the incidence, aetiology, and outcomes of subsequent revascularisation from a large, prospective refractory angina database with 1,363 ‘no option’ patients followed for a median of 5.1 years,” the authors write.

Of the 1,363 patients in the database, from the OPTIMIST programme, 342 (25.1%) underwent revascularisation within 2.2 years of receiving a “no option” label. Most of these underwent PCI (20.1%), with the remainder undergoing CABG (3.2%) or both (1.8%). Sharma et al comment: “Patients who were subsequently revascularised had significantly lower mortality than patients who were not (2%/year vs. 4.4% per year; p<0.001).

A paired analysis of baseline and subsequent angiographic records for 181 PCI patients showed that just under half underwent PCI for a new lesion (48%), with 31% undergoing PCI for an existing lesion and 21% for a restenosis. According to a review of five-year survival post revascularisation, patients who required PCI for a pre-existing lesion had higher mortality (23%) compared with those undergoing CABG (15%), those with new lesions (11%), and those with restenosis (11%).

Sharma and Henry conclude: “Given that new lesions are the most common reason for revascularisation, with resulting improvement in survival, careful consideration should be given to further investigation and appropriate invasive management in patients with refractory angina irrespective of any prior classification of ‘no option’.”

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