Refractory Angina Management — EECC MCQ

Correct answer: D — Enhanced external counterpulsation (EECP), spinal cord stimulation, coronary sinus reducer device, and cardiac rehabilitation — these are options for refractory angina when revascularisation is not possible

This man has refractory angina: persistent ischaemic chest pain despite optimal anti-anginal therapy, with diffuse obstructive CAD for which PCI or CABG is not feasible. Management is therefore symptom- and quality-of-life-focused in a specialist refractory angina/MDT setting, rather than simply increasing drugs beyond tolerated doses. Options that may be considered include enhanced external counterpulsation (EECP), neuromodulation such as spinal cord stimulation, coronary sinus reducer implantation in appropriately selected patients and experienced centres, and structured cardiac rehabilitation/exercise and self-management support. These are not presented as curative or prognostic treatments, but as additional strategies when conventional drug therapy and revascularisation have been exhausted. Heart transplantation is not indicated for isolated refractory angina with LVEF 45%, and long-term opioids are not standard angina management.

Reference: British Cardiovascular Society. The Role of Coronary Sinus Reducer Devices in Patients with Refractory Angina, 2024. https://britishcardiovascularsociety.org.uk/wp-content/uploads/Editorials/The-Role-of-Coronary-Sinus-Reducer-Devices-in-Patients-with-Refractory-Angina-2.pdf