REFRACTORY ANGINA-PECTORIS IN END-STAGE CORONARY-ARTERY DISEASE - EVOLVING THERAPEUTIC CONCEPTS

Refractory angina pectoris in coronary artery disease is defined as th e persistence of severe anginal symptoms despite maximal conventional antianginal combination therapy. Further, the option to use an invasiv e revascularization procedure such as percutaneous coronary balloon an gioplasty or aortocoronary bypass grafting must be excluded on the bas is of a recent coronary angiogram. This coronary syndrome, which repre sents end-stage coronary artery disease, is characterized by severe co ronary insufficiency but only moderately impaired left ventricular fun ction. Almost all patients demonstrated severe coronary triple-vessel disease with diffuse coronary atherosclerosis, had had one or more myo cardial infarctions, and had undergone aortocoronary bypass grafting ( 70% of cases), We present three new approaches with antiischemic prope rties: long-term intermittent urokinase therapy, transcutaneous and sp inal cord electrical nerve stimulation, and transmyocardial laser reva scularization.