A Refractory angina 72 Number 72 - March 2017

Ischemic heart disease (IHD) is a main determinant of global health and mortality. Despite significant advances in therapeutic options, many patients complain with persistent symptoms and/or signs of myocardial ischemia (ie, refractory angina). Main therapeutic strategies used in angina patients aim at either reducing the effects of coronary stenosis on coronary blood flow or at removing the coronary stenosis itself. However, obstructive coronary artery disease is not synonymous with IHD. Indeed, a number of other factors can precipitate myocardial ischemia, including microvascular dysfunction, focal or diffuse spasm, and altered mitochondrial metabolism. It is therefore not surprising that therapeutic strategies that target epicardial coronary stenosis are not effective in all IHD patients. When approaching a patient with angina, the multiple pathophysiology model should be adopted at all levels, including diagnostic and treatment strategies. Angina should be considered refractory once the underlying mechanism has been identified and the targeted treatment has failed to control symptoms. This attitude could help stratify risk and augment treatment strategies, in this way optimizing resource utilization and improving cardiovascular outcome in the individual patient. L Heart Metab. 2017;72:4-8