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      Spinal cord stimulation in the treatment of refractory angina: systematic review and meta-analysis of randomised controlled trials

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          Abstract

          Background

          The aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina.

          Methods

          We searched a number of electronic databases including Medline, Embase and Cochrane Library up to February 2008 to identify randomised controlled trials (RCTs) reporting exercise capacity, ischemic burden, functional class, quality of life, usage of anti-anginal medication, costs and adverse events including mortality. Results were reported both descriptively for each study and using random effects meta-analysis. Given the variety in outcomes reported, some outcome results were pooled as standardised mean differences (SMD) and reported in standard deviation units.

          Results

          Seven RCTs were identified in a total of 270 refractory angina patients. The outcomes of SCS were found to be similar when directly compared to coronary artery bypass grafting (CABG) and percutaneous myocardial laser revascularisation (PMR). Compared to a 'no stimulation' control, there was some evidence of improvement in all outcomes following SCS implantation with significant gains observed in pooled exercise capacity (SMD: 0.76, 0.07 to 1.46, p = 0.03) and health-related quality of life (SMD: 0.83, 95% CI: 0.32 to 1.34, p = 0.001). Trials were small and were judged to range considerably in their quality. The healthcare costs of SCS appeared to be lower than CABG at 2-years follow up.

          Conclusion

          SCS appears to be an effective and safe treatment option in the management of refractory angina patients and of similar efficacy and safety to PMR, a potential alternative treatment. Further high quality RCT and cost effectiveness evidence is needed before SCS can be accepted as a routine treatment for refractory angina.

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          Most cited references31

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          Cochrane Handbook for Systematic Reviews of Interventions

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            The problem of chronic refractory angina; report from the ESC Joint Study Group on the Treatment of Refractory Angina.

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              Methodology and reports of systematic reviews and meta-analyses: a comparison of Cochrane reviews with articles published in paper-based journals.

              Review articles are important sources of information to help guide decisions by clinicians, patients, and other decision makers. Ideally, reviews should include strategies to minimize bias and to maximize precision and be reported so explicitly that any interested reader would be able to replicate them. To compare the methodological and reporting aspects of systematic reviews and meta-analyses published by the Cochrane Collaboration with those published in paper-based journals indexed in MEDLINE. The Cochrane Library, issue 2 of 1995, and a search of MEDLINE restricted to 1995. All 36 completed reviews published in the Cochrane Database of Systematic Reviews and a randomly selected sample of 39 meta-analyses or systematic reviews published in journals indexed by MEDLINE in 1995. Number of authors, trials, and patients; trial sources; inclusion and exclusion criteria; language restrictions; primary outcome; trial quality assessment; heterogeneity testing; and effect estimates. Updating by 1997 was evaluated. Reviews found in MEDLINE included more authors (median, 3 vs 2; P<.001), more trials (median, 13.5 vs 5; P<.001), and more patients (median, 1280 vs 528; P<.001) than Cochrane reviews. More Cochrane reviews, however, included a description of the inclusion and exclusion criteria (35/36 vs 18/39; P<.001) and assessed trial quality (36/36 vs 12/39; P<.001). No Cochrane reviews had language restrictions (0/36 vs 7/39; P<.01). There were no differences in sources of trials, heterogeneity testing, or description of effect estimates. By June 1997, 18 of 36 Cochrane reviews had been updated vs 1 of 39 reviews listed in MEDLINE. Cochrane reviews appear to have greater methodological rigor and are more frequently updated than systematic reviews or meta-analyses published in paper-based journals.
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                Author and article information

                Journal
                BMC Cardiovasc Disord
                BMC Cardiovascular Disorders
                BioMed Central
                1471-2261
                2009
                25 March 2009
                : 9
                : 13
                Affiliations
                [1 ]Health Services Research, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK
                [2 ]Department of Cardiology, Thorax Centre, University Medical Centre Groningen, The Netherlands
                [3 ]Pain Clinic, Morges Hospital, Morges, Switzerland
                Article
                1471-2261-9-13
                10.1186/1471-2261-9-13
                2667170
                19320999
                1f5b96a2-4105-4443-89e8-de15ac0f7fd4
                Copyright © 2009 Taylor et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 16 June 2008
                : 25 March 2009
                Categories
                Research Article

                Cardiovascular Medicine
                Cardiovascular Medicine

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