Therapeutic angiogenesis for management of refractory angina
- Michael Simons, MD
Michael Simons, MD
- Robert W Berliner Professor of Medicine
- Yale University School of Medicine
Advances in medical therapy and mechanical revascularization have significantly improved outcomes and the quality of life in patients with angina pectoris. In addition, the widespread application of drug-eluting stents has greatly expanded the ability of percutaneous coronary intervention (PCI) to treat patients with complex coronary anatomy. (See "Stable ischemic heart disease: Overview of care" and "Stable ischemic heart disease: Indications for revascularization" and "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention".)
Despite these advances, there are patients with angina that is refractory to medical therapy who are not candidates for traditional revascularization (PCI or coronary artery bypass graft surgery [CABG]) because of the inability to achieve complete revascularization or the high risk of CABG .
Such patients provide part of the rationale for novel therapeutic strategies to improve both prognosis and the quality of life. Therapeutic angiogenesis is one such option and will be reviewed here [2,3]. This approach is also being investigated for treatment of patients with peripheral artery disease, including both intermittent claudication and critical limb ischemia. (See "Treatment of chronic lower extremity critical limb ischemia", section on 'Stimulation of angiogenesis'.)
Other investigational strategies, such as transmyocardial laser revascularization and new medications, are discussed separately. (See "Transmyocardial laser revascularization for management of refractory angina" and "New therapies for angina pectoris".)
The goal of therapeutic angiogenesis is the induction of new coronary arterial vessels that can effectively provide blood supply to the area of myocardium subtended by diseased or occluded native coronary arteries. These "native bypass" vessels could then relieve myocardial ischemia, improve regional and global left ventricular performance, lessen symptoms of angina, and potentially improve patient prognosis .
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- GENERAL CONCEPTS
- Restoration of arterial blood supply
- CHALLENGES IN CLINICAL TRIALS
- Patient selection
- Delivery of growth factors
- Protein versus gene therapy
- Trial end points
- Pro-angiogenic agents
- VIVA trial
- KAT trial
- Euroinject One trial
- NORTHERN Trial
- FIBROBLAST GROWTH FACTORS
- HEPARIN AND ADENOSINE
- POTENTIAL COMPLICATIONS