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What are less invasive alternatives to an angioplasty in Singapore?

Cardiology

My private cardiologist has recommended an angioplasty to unblock my heart vessels. I would like to know what are alternative options that are less invasive, as compared to an angioplasty?

DOCTOR’S ANSWER (1)

I do not know of any suitable longterm less invasive alternatives to angioplasty, bar optimal medical therapy.

There are centres abroad that offer EECP ( Enhanced external counterpulsation) but bear in mind that this is recommended for incessant angina, and is only effective for microvascular disease as adjunct therapy (i.e when the disease is in the small vessels not visible to the eye on angiogram and there is no narrowing or blockage in the larger vessels).

Though its a therapy that has been around for quite sometime, but unfortunately the evidence based on peer-reviewed literature  only supports its use in endstage refractory angina which is not amenable to either angioplasty/bypass or optimal medical therapy.   

I attach relevant guidelines below:-

UK:

NICE Guideline: (see page 15 of EECP angina) National Institute for Clinical Effectiveness (NICE) currently states that the evidence for the effectiveness of EECP is weak. Therefore generally speaking it’s no longer recommended in the UK as a treatment for stable angina.  

1.6 Pain interventions Enhanced external counterpulsation (EECP) NICE CG126 states that EECP should not be offered to manage stable angina. A Cochrane review by Amin et al. (2010) investigated the effects of EECP in chronic stable angina or refractory stable angina.

One RCT (n=139) was found examining hour-long sessions of EECP once or twice daily for 35 hours over 4 to 7 weeks versus sham treatment. The authors of the Cochrane review deemed the trial to be of poor methodological quality (for example, exclusion of those with severe symptoms of angina), with incomplete reporting of the primary outcome, limited follow-up of secondary outcomes, and flawed statistical analysis.

They therefore concluded that the evidence for EECP in stable angina was inconclusive. The RCT was originally reported on in 1999 and information about it was available during the development of NICE CG126 when the ‘do not do’ recommendation was made.

No subsequently published studies were found by the Cochrane review and thus the results are consistent with the current guideline. Key reference Amin F, Al Hajeri A, Civelek B et al. (2010) Enhanced external counterpulsation for chronic angina pectoris. Cochrane Database of Systematic Reviews issue 2: CD007219 

USA:
AHA guidelines:  

B. Enhanced External Counterpulsation Another nonpharmacological technique that has been described for treatment of patients with chronic stable angina is known as EECP.

EECP was evaluated in a randomized, placebo-controlled multicenter trial to determine its safety and efficacy. Patients (n=139) with chronic stable angina, documented CAD, and a positive exercise treadmill test were randomly assigned to receive EECP (35 hours of active counterpulsation) or inactive EECP over a 4- to 7-week period.

The authors concluded that EECP decreased angina frequency (P<0.05) and improved time to exercise-induced ischemia (P=0.01). Two multicenter registry studies that included 978 patients from 43 centers and 2289 patients from more than 100 centers evaluated the safety and effectiveness of EECP in treating chronic stable angina.

These studies found the treatment to be generally well tolerated and efficacious; anginal symptoms were improved in approximately 75% to 80% of patients. However, additional clinical trial data are necessary before this technology can be recommended definitively.

Europe: class of recommendation is Class IIA (ie not recommended as first line therapy)


Dr Nandakumar Ramasami
MBBS, MRCP, FRCP

MOUNT ELIZABETH NOVENA SPECIALIST CENTRE

38 IRRAWADDY ROAD
c
#05 - 34/35 Singapore 329563


689 views 6 Aug 2018
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