From the Multidisciplinary Pain Centre (C.M., T.E., H.N.), Department of
Medicine, Östra Hospital and the Departments of Neurosurgery (L.-E.A.),
Neurology (C.B.), Cardiology (H.E., A.H.), and Thoracic Surgery (S.L.),
Sahlgren's Hospital, Gothenburg, Sweden.
Methods and Results—One hundred four patients were randomized
(SCS, 53; CABG, 51). The patients were assessed with respect to
symptoms, exercise capacity, ischemic ECG changes during
exercise, rate-pressure product, mortality, and
cardiovascular morbidity before and 6 months after the
operation. Both groups had adequate symptom relief
(P<.0001), and there was no difference between SCS and
CABG. The CABG group had an increase in exercise capacity
(P=.02), less ST-segment depression on maximum
(P=.005) and comparable (P=.0009)
workloads, and an increase in the rate-pressure product both at
maximum (P=.0003) and comparable (P=.03)
workloads compared with the SCS group. Eight deaths occurred during the
follow-up period, 7 in the CABG group and 1 in the SCS group. On an
intention-to-treat basis, the mortality rate was lower in the SCS group
(P=.02). Cerebrovascular morbidity was also lower in the
SCS group (P=.03).
Conclusions—CABG and SCS appear to be equivalent methods in terms
of symptom relief in this group of patients. Effects on
ischemia, morbidity, and mortality should be considered in the
choice of treatment method. Taking all factors into account, it seems
reasonable to conclude that SCS may be a therapeutic alternative for
patients with an increased risk of surgical complications.
Revascularization procedures, ie, coronary
artery bypass grafting (CABG) and percutaneous
transluminal coronary angioplasty (PTCA), are standard
treatments in severe angina pectoris. There are several groups of
patients for whom CABG is known to be associated with an increased
complication risk, eg, patients with unsuitable coronary
anatomy requiring extended surgical
procedures15 ; patients with low ejection
fractions16 ; patients with concomitant
extracardiac disease such as diabetes mellitus,17
renal dysfunction,18 cerebrovascular
disease,18 19 20 or peripheral vascular
disease21 ; and patients who have previously
undergone CABG.15 17 Until now, SCS has been used
in the treatment of severe angina pectoris despite optimum medication
in patients who are not accessible for
revascularization.
The SCS device is implanted under local anesthesia,
and the complication risk is therefore considered to be lower than in
CABG, in which the patient must be subjected to cardiopulmonary
bypass/extracorporeal circulation and cardioplegia.
Therefore, the aim of the present study was to compare the results
of SCS and CABG in patients accepted for CABG who had an increased
intraoperative and postoperative complication risk and lack of
prognostic benefit from CABG in a randomized, prospective trial.
Because the criteria stated above limited the number of patients
eligible for the study, the number of patients enrolled was based on an
estimate of the realistic enrollment frequency over a 3-year period.
The inclusion period was limited because surgical and anesthesiological
techniques develop rapidly. A longer inclusion period could have
resulted in differences between patients included early and late in the
study, which would have made the results more difficult to
interpret.
Eligibility
Patients who were considered to have only symptomatic
indication for CABG according to the American College of
Cardiology/American Heart Association guidelines (ie,
no prognostic benefit),22 to run an increased
risk of surgical complications (Table 1
One hundred sixteen patients were selected from the patient population
accepted for CABG. These patients were subjected to a second
assessment, including a thorough physical examination and case history
by the two cardiologists conducting the study in which inclusion and
exclusion criteria were carefully weighed. These cardiologists have
extensive experience of SCS treatment in ischemic heart
disease.
Patients were excluded if they were considered unsuitable for CABG,
unable to manage the SCS device, or unable to follow the study
protocol. Patients with myocardial infarction within the last 6 months
were excluded.
After these examinations, 104 patients who complied with the inclusion
criteria remained, which amounted to 3.2% of 3272 patients accepted
for CABG in the region during the inclusion period.
The study was approved by the ethical committee of the University of
Gothenburg. The patients received both written and thorough verbal
information. After informed consent, each patient was randomized.
Patients
At the time of inclusion, 2 of 104 subjects worked full-time, 5 worked
part-time, 21 were on sick leave due to cardiac disease, and 76 had
retired. Additional patient data are presented in Table 2
Stratified randomization was not used. A retrospective scoring for risk
of surgical complications according to Higgins et
al18 was performed and yielded a mean of 4.2
points. However, differences between the two groups were negligible
except for current smoking and nephrologic disease.
End Points
Spinal Cord Stimulation: Surgical Technique and
Equipment
The skin incision was made at the midline in the midthoracic region.
The epidural space was punctured at the level of T6. A Tuohy-type
needle was advanced in the midline through the intervertebral spaces
into the epidural space. The electrode tip was placed at the level of
T1 to T2. The pulse generator was placed in a subcutaneous pouch below
the left costal arch. An extension lead was tunneled subcutaneously to
the midline incision and connected to the electrode. The pulse
generator was telemetrically programmed with two preset stimulation
strengths, one stronger that was used in case of established anginal
pain and one weaker that was used as prophylactic
treatment. The latter was used for at least 2 hours four times daily. A
commercially available electrical device (Medtronic) was used. The
pulse generator is turned on or off when the patient quickly touches
the skin over the pulse generator with an external magnet. The patient
can also use the magnet to switch between the two preset stimulation
strengths.
Exercise Tests
Comparable workload was defined as the lowest individual maximum
workload that a patient achieved in both tests and thus
represents the highest workload that can be used for a
comparison at a similar level of cardiac stress.
Symptom Relief
Mortality and Morbidity
Statistical Methods
Differences in mortality and morbidity were assessed by use of
Kaplan-Meier probabilities and Cox proportional hazard
models.24 Morbidity was assessed as a combined
end point, ie, including both fatal and nonfatal cardiac and
cerebrovascular events. In each Cox regression calculation, a patient
was allowed to participate with only one event.
The CABG group had an increase in exercise capacity (P=.02)
and less ST-segment depression on maximum (P=.005) and
comparable (P=.0009) workloads than the SCS group. The
rate-pressure products on maximum (P=.0003) and
comparable (P=.03) workloads were higher for CABG than for
SCS subjects (Table 4
Follow-up
In the SCS group, four patients were lost to follow-up. Two
patients had emergency CABG because of unstable angina and were lost to
follow-up. One patient died before follow-up. The reasons for the loss
of the remaining three patients (two CABG and one SCS patient) to
follow-up were lack of compliance or medical complications not related
to the study.
Cardiac and Cerebrovascular Mortality and
Morbidity
Cardiac events did not differ between the groups. There were 8
cerebrovascular events in the CABG group and 2 in the SCS group. This
difference in cerebrovascular morbidity was statistically significant
(P=.03). Three patients in the CABG group and 2 patients in
the SCS group had both cardiac and cerebrovascular events. Total
cardiac and cerebrovascular morbidity (including patients who had one
or more fatal or nonfatal cardiac or cerebrovascular event) was 14
patients in the CABG group and 8 in the SCS group, which was not
statistically significant (P=.08).
Crossover
Both treatment methods had a similar effect on symptom relief, decrease
in anginal attack frequency, and consumption of short-acting nitrates.
However, CABG led to increased exercise capacity and decreased
ST-segment depression at follow-up compared with SCS. The mortality in
the CABG group was significantly higher on an intention-to-treat
basis.
The treatment of patients with severe angina pectoris and increased
complication risk in association with cardiac surgery is a clinical
problem because the success rate in this patient group is considered to
be limited and the mortality rate is elevated. Still, these patients
have disabling symptoms, and therapeutic alternatives to CABG have
previously been lacking.
Both methods had satisfactory effects on symptom relief, decrease in
anginal attacks, and consumption of short-acting nitrates. In these
respects, the strategies did not differ. This is a crucial observation
because the indications for invasive procedures were based only on
symptoms in all patients.
CABG had a significant effect on ischemic variables such as
exercise capacity and ST-segment depression, whereas SCS did not affect
these variables. These effects of CABG were as expected and are in
accordance with those reported in previous
studies.25 26 The lack of effect of SCS on
exercise capacity and ST-segment depression in the present study
was in contrast with previous studies on the immediate effects of
electrostimulation on experimentally induced myocardial
ischemia, in which a consistent and highly reproducible
anti-ischemic effect has been
observed.6 7 8 9 10 12 13 14 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
In the present study, SCS was discontinued for 24 hours before the
exercise test. This was different from the design used in previous
studies, in which ischemia monitoring has been performed during
ongoing stimulation. The reason for choosing to discontinue the
stimulation in the present study was the need to assess the
possible long-term effects on myocardial
ischemia,9 because the
anti-ischemic effect during ongoing stimulation has been
thoroughly documented in earlier
studies.6 7 8 9 10 12 13 14 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 The results of the
present study indicate that there are no long-term effects on
myocardial ischemia after treatment has been discontinued for
24 hours. This should be considered when the results of the present
study are evaluated, ie, exercise tests should be performed during
ongoing stimulation. Furthermore, in the clinical setting, it is
essential to continue daily stimulation even if the patient is free
from cardiac symptoms. The study design of the above-mentioned studies
on the immediate effects of SCS on myocardial ischemia is more
similar to the daily-life setting, in which the patient uses the
stimulator in situations in which myocardial ischemia
occurs.
Mortality was significantly higher in the CABG group when calculated on
a strict intention-to-treat basis. However, three of seven patients
died while waiting for surgery.
Cardiac morbidity did not differ between the two strategies.
Cerebrovascular morbidity was significantly higher in the CABG group.
This was expected because stroke is a well-known complication in
connection with bypass surgery.45
Study Limitations
The study was not blinded because the surgical procedures differ
significantly. Thus, it was not possible to blind the treatment to
either patient or physician. However, tasks were strictly divided among
the investigators to minimize bias, ie, the investigators involved in
the tests were not engaged in patient contact and follow-up and vice
versa.
As pointed out, it would have been an advantage to have two exercise
tests at follow-up, the second one during ongoing stimulation to
evaluate the well-known immediate anti-ischemic effects of SCS
compared with CABG. This was not done for practical reasons.
Conclusions
Received October 9, 1997;
revision received November 12, 1997;
accepted December 1, 1997.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Electrical Stimulation Versus Coronary Artery Bypass Surgery in Severe Angina Pectoris
The ESBY Study
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—Spinal cord stimulation
(SCS) has been shown to have antianginal and anti-ischemic
effects in severe angina pectoris. The present study was performed
to investigate whether SCS can be used as an alternative to
coronary artery bypass grafting (CABG) in selected patient
groups, ie, patients with no proven prognostic benefit from CABG and
with an increased surgical risk.
Key Words: bypass • angina • electrical stimulation
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Spinal cord
stimulation (SCS), or epidural spinal electrical stimulation, has been
used in the treatment of chronic neurogenic pain for several
years.1 2 SCS has also been used in the treatment
of peripheral vascular disease with satisfactory clinical
results in terms of increased local blood flow and promoted healing of
ischemic ulcers.3 4 5 Since 1985, SCS has
been used to treat intractable angina pectoris with promising clinical
results in terms of symptom relief and reduction in myocardial
ischemia.6 7 8 9 10 Eighty percent of the
patients treated with SCS at our center enjoy a lasting, good effect of
the treatment in terms of reduced frequency of anginal pain and
consumption of short-acting nitrates.9 In a
similar study from The Netherlands, the reported mortality rate was
similar to that of patients with coronary artery disease and
stable angina pectoris.11 The antianginal effect
is secondary to an anti-ischemic effect, which in turn seems to
be due to a reduction in myocardial oxygen
consumption6 ; however, a redistribution of
coronary blood flow cannot be excluded.12
Furthermore, it has been shown unequivocally that ongoing myocardial
ischemia during stimulation treatment gives rise to anginal
pain. Thus, the treatment does not deprive the patient of a warning
signal.6 7 9 13 14
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
The present study was designed as a randomized, prospective,
open comparison between CABG and SCS in a selected patient group, ie,
patients with no proven prognostic benefit from CABG and with an
increased risk of complications. Patients were included over a period
of 36 months from January 1992 to March 1995.
All patients being evaluated for
revascularization procedures by a team consisting
of cardiac surgeons, interventional cardiologists, and the referring
physician at the routine daily revascularization
conferences at Östra Hospital and Sahlgren's Hospital,
Gothenburg, Sweden, were evaluated for eligibility in the study. These
physicians were not involved in this study. The evaluation was based on
strict conventional clinical criteria in which several factors
were considered. 
),
and to be unsuitable for PTCA were invited to participate in the study.
Patients with coronary anatomy who were considered
unavailable for complete revascularization with
PTCA treatment because of either diffuse, extensive coronary
artery disease or chronic multiple stenoses were considered
unsuitable for this procedure and thereby eligible for inclusion in
this study.
View this table:
[in a new window]
Table 1. Factors Considered Important for Surgical
Outcome
One hundred four patients were included in the study (mean age,
68.9 years; 21 women with a mean age of 69.4 years and 83 men with a
mean age of 68.9 years). Mean ejection fraction was 57.5% (range, 19%
to 86%). Fifty-one patients were randomized to CABG (mean age, 68.7
years; 9 female patients [18%]), and 53 were randomized to SCS (mean
age, 72.2 years; 12 female patients [23%]). The time from inclusion
to operation was on average 1.9 months in the CABG group and 1.0 month
in the SCS group. This difference was statistically significant
(P<.0001). .
View this table:
[in a new window]
Table 2. Patient Characteristics
The aim of the ESBY study was to compare CABG with SCS on the
basis of an "intention-to-treat" design. The primary goal was to
compare the effect on the end points of symptoms and myocardial
ischemia. Effects on symptoms were assessed in terms of
frequency of anginal attacks, consumption of short-acting
nitrates, and self-estimated symptom relief. Myocardial
ischemia was assessed by means of exercise tests before and 6
months after surgery. Secondary end points were total mortality and
morbidity. Mortality was subgrouped into cardiac death and death from
other causes. Morbidity was subgrouped into
cardiovascular and cerebrovascular morbidity.
The stimulation equipment was implanted by use of a sterile
technique. The patient was placed on an x-ray–translucent table. The
operation was performed under local anesthesia to allow the
patient and the surgeon to communicate during the
perioperative test stimulation. The electrode was
positioned so that the patient felt a prickling sensation in the region
of anginal pain. The adequate position is when the stimulation produces
paresthesia covering the area of radiation of anginal pain, ie,
confirming that the spinal segments in which the cardiac innervation is
located are stimulated.
Exercise tests were performed according to a standardized
protocol with a 12-lead ECG on a bicycle ergometer. The tests were of a
stepwise, continuous, and maximum design, starting at 30 or 50 W,
depending on the patient's estimated capacity. The workload was
increased by 10 W/min. Blood pressure, heart rate, and ECG changes were
recorded at each level. Exercise was stopped when the patient
experienced maximum effort, chest pain rated 6 to 7 of 10 on the Borg
scale or dyspnea rated 6 to 7 of 10, or showed signs of severe
myocardial ischemia (>3-mm ST-segment depression) or
hypotension. The calculated measures were exercise capacity,
ischemic ECG changes (ie, degree of ST-segment depression), and
the rate-pressure products at comparable and maximum workloads.
Patients randomized to SCS had stimulation treatment discontinued 24
hours before the second exercise test.
Clinical outcome was recorded on a questionnaire given to
the patient shortly after the exercise tests. Patients reported their
frequency of anginal attacks and consumption of short-acting nitrates
per week. At follow-up, the subjective treatment effect was
recorded with the use of a scale ranging from 1 (better or free
from symptoms) to 2 (unchanged or worse).
Mortality was characterized as a fatality occurring between the
inclusion examination date and 6 months thereafter. Cardiac events were
monitored as myocardial infarction, angina pectoris, or heart failure
that was fatal or required hospital admission. A cerebrovascular event
was characterized as acute focal cerebral ischemia lasting >24
hours (definite stroke) and corresponding focal signs at the separate
follow-up neurological examination that were not noted at the
preinclusion examination.
Efficacy parameters (ischemia and symptom
variables) were analyzed by use of repeated measures ANOVA,
with randomization as the grouping variable. Tests were
conservatively calculated as described by Greenhouse and
Geisser.23
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Effects on Symptoms and Myocardial Ischemia
In both groups, a majority of the patients (79.5% in the CABG
group and 83.7% in the SCS group) had a good self-estimated treatment
effect, and the treatment methods did not differ in this respect. Both
treatment methods caused a decrease in the frequency of anginal attacks
(P<.0001) and consumption of short-acting nitrates
(P<.0001). There were no differences between the groups in
these respects (Table 3).
View this table:
[in a new window]
Table 3. Effect on Anginal Symptoms ).
View this table:
[in a new window]
Table 4. Exercise Tests
Fifteen patients did not participate in the follow-up
examination. Eleven of these were in the CABG group. Of these, 7 died
before the follow-up appointment and 2 were not operated on, one
because the risk was reconsidered (unacceptably high) after the first
evaluation and the other because he became free from anginal symptoms
before surgery.
Eight patients died between randomization and follow-up.
Seven patients in the CABG group died, three before surgery. Six deaths
were cardiac in nature, and the seventh patient had both myocardial as
well as computer tomography–verified cerebral infarctions. One patient
in the SCS group died of a myocardial infarction 3 months after
implantation. The mortality rate was 13.7% in the CABG group and 1.9%
in the SCS group, respectively. This difference in mortality was
significant (P=.02) on an intention-to-treat basis (Tables 5 and 6).
View this table:
[in a new window]
Table 5. Mortality and Morbidity
View this table:
[in a new window]
Table 6. Causes of Mortality and Morbidity
Three patients randomized to CABG received SCS instead; one
patient refused CABG and one was reevaluated immediately before CABG
and considered to present an unacceptably high
perioperative risk. The third patient was implanted
with an SCS device 2 months after CABG surgery because of a quick
relapse of severe angina. Three patients randomized to SCS had a CABG
because of unstable angina.
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
The patients included in the present study were selected by
use of the criteria mentioned above: no prognostic indication for CABG
and increased risk of surgical complications. This selection was made
after a thorough individual evaluation of all the factors known to be
associated with an increased risk of surgical complications (see
introduction and Table 1
). Stratified randomization was not used owing
to the limited number of patients. A retrospective scoring for surgical
risk according to Higgins et al18 was performed
to further describe the patients. This yielded a mean score of 4.2
points, which is above the reported cutoff point for increased
morbidity. However, because the scoring was done retrospectively, it
should be interpreted with caution. This scoring system was not in use
at the start of the study, and one of the factors considered of
importance for surgical outcome at inclusion was complicated
coronary anatomy, which is not considered in this
scoring system. However, differences between the two groups were
negligible except for current smoking, which had a higher
representation in the CABG group, and nephrologic disease,
which occurred more frequently in the SCS group.
This study included a limited number of patients and a limited
follow-up time, and the mortality and morbidity results should
therefore be interpreted cautiously.
The results of the present study indicate that SCS is an
equivalent alternative to bypass surgery in this patient group to
obtain symptom relief. The more pronounced anti-ischemic effect
of CABG could be explained by the fact that treatment was discontinued
for patients in the SCS group, unlike the CABG patients. When all
aspects are taken into consideration, it seems reasonable to conclude
that SCS may be a therapeutic alternative for patients with an
increased risk of surgical complications and no prognostic benefit from
surgery. However, these results warrant further research in this
field.
Acknowledgments
The study was supported by the Faculty of Medicine, University
of Göteborg, the Swedish National Heart-Lung Foundation, and the
Swedish Medical Research Council (projects B-93–19x-10404–01 and
B96–19X-11239–02B).
Footnotes
Reprint requests to Clas Mannheimer, MD, PhD, Multidisciplinary Pain Centre, Department of Internal Medicine, Östra University Hospital, 416 85 Göteborg, Sweden.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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 |
|
 R. A. Lange and L. D. Hillis Transmyocardial Laser Revascularization N. Engl. J. Med., September 30, 1999; 341(14): 1074 - 1076. [Full Text]
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|
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I A M TenVaarwerk, G A J Jessurun, M J L DeJongste, C Andersen, C Mannheimer, T Eliasson, W Tadema, and M J Staal Clinical outcome of patients treated with spinal cord stimulation for therapeutically refractory angina pectoris Heart, July 1, 1999; 82(1): 82 - 88. [Abstract] [Full Text] [PDF]
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