Refractory angina: mechanisms and stratified treatment in obstructive and non-obstructive chronic myocardial ischaemic syndromes
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
The diagnosis of refractory angina has conventionally been limited to patients with angina and ischaemia secondary to obstructive atherosclerotic epicardial coronary disease who experience persistent symptoms despite optimal pharmacological and revascularization therapies. It is now well-established that angina may also be caused by ischaemia resulting from coronary microcirculatory disorders, coronary vasospasm, and bridging in the absence of obstructive epicardial coronary disease or after “successful” revascularization. This increasingly prevalent and symptomatic group of patients, with both angina and demonstrable ischaemia, have been excluded from the conventional definition of refractory angina. In patients with obstructive epicardial coronary disease, disturbed microcirculatory and vasomotor function, amongst other ischaemic mechanisms, may account for continuing symptoms despite revascularization. Under-recognition of these mechanisms results in inadequate treatment and symptom persistence. In this review, a redefinition of refractory angina is proposed to include the full spectrum of patients experiencing persistent angina despite current maximal guideline-directed medical and revascularization therapies. Systematic approaches for comprehensive investigation are suggested to identify underlying mechanisms of ischaemia and stratify treatments accordingly. The complex needs of patients with refractory angina are likely best addressed by an inter-disciplinary Angina Heart Team with the aim of improving patient symptoms, quality of life, and clinical outcomes.
Date Issued
2025-10-07
Date Acceptance
2025-04-09
Citation
European Heart Journal, 2025, 46 (38), pp.3738-3757
ISSN
0195-668X
Publisher
Oxford University Press (OUP)
Start Page
3738
End Page
3757
Journal / Book Title
European Heart Journal
Volume
46
Issue
38
Copyright Statement
© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
License URL
Identifier
10.1093/eurheartj/ehaf284
Subjects
CAD, coronary artery disease
CBT, cognitive behavioural therapy
CFVR, coronary flow velocity reserve
CMD, coronary microvascular dysfunction
CMR, cardiac MRI
CSR, coronary sinus reducer
CT, computed tomography
ECSWT, extracorporeal shockwave therapy
EECP, enhanced external counterpulsation
ETT, exercise tolerance test
LIPUS, low-intensity pulsed ultrasound
PET, positron emission tomography
SCS, spinal cord stimulation
SENS, subcutaneous electrical nerve stimulation
SGB, stellate ganglion block
TENS, transcutaneous electrical nerve stimulation
VSA, vasospastic angina Refractory angina pectoris • Chronic coronary syndromes • INOCA • ANOCA • Non-acute myocardial ischaemic syndromes
Publication Status
Published
Article Number
ehaf284
Date Publish Online
2025-07-01