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      Cost-Effectiveness of Spinal Cord Stimulation versus Coronary Artery Bypass Grafting in Patients with Severe Angina Pectoris – Long-Term Results from the ESBY Study


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          The present study is a 2-year follow-up of the 104 patients participating in the ESBY study (Electrical Stimulation versus Coronary Artery Bypass Surgery in Severe Angina Pectoris), a randomised prospective study including patients with increased surgical risk and no prognostic benefit from revascularisation. Hospital care costs, morbidity and causes of death after spinal cord stimulation (SCS) and coronary artery bypass grafting (CABG) were assessed, as well as the complication rate of SCS treatment. SCS proved to be a less expensive symptomatic treatment modality of angina pectoris than CABG (p < 0.01). The SCS group had fewer hospitalisation days related to the primary intervention (p < 0.0001) and fewer hospitalisation days due to cardiac events (p < 0.05). The groups did not differ with regard to causes of death. There were no serious complications related to the SCS treatment.

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          Most cited references 6

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          Physiology of spinal cord stimulation: review and update.

          Spinal cord stimulation (SCS) was an outgrowth of the well-known gate control theory presented by Melzack and Wall in 1965. Although the method has been used to treat chronic severe pain for more than three decades, very little was known about the physiological and biochemical mechanisms behind the beneficial effects until recently. We now know that SCS activates several different mechanisms to treat different types of pain such as neuropathic and ischemic. In general, these mechanisms seem most dependent on activation of only a few segments of the spinal cord. However, both animal studies and human observations have indicated that supraspinal circuits may contribute as well. In the treatment of neuropathic pain, intermittent SCS may give several hours of pain relief after cessation of the stimulation. This protracted effect indicates long-lasting modulation of neural activity involving changes in the local transmitter systems in the dorsal horns. In ischemic pain, animal experiments demonstrate that inhibition of afferent activity in the spinothalamic tracts, long-term suppression of sympathetic activity, and antidromic effects on peripheral reflex circuits may take part in the pain alleviation. Moderate SCS intensities seem to evoke sympathetic inhibition, but higher stimulation intensities may induce antidromically mediated release of vasoactive substances, eg, the calcitonin gene-related peptide (CGRP), resulting in peripheral vasodilation. The anti-ischemic effect of SCS in angina pectoris due to intermittent coronary ischemia probably occurs because application of SCS appears to result in a redistribution of cardiac blood supply, as well as a decrease in tissue oxygen demand. Recent studies indicate that SCS modulates the activity of cardiac intrinsic neurons thereby restricting the arrythmogenic consequences of intermittent local coronary ischemia. The present state of knowledge is briefly reviewed and recent research directions outlined.
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            Long-term results of RITA-1 trial: clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting

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              Dorsal column stimulation for pain relief from intractable angina pectoris.

              Dorsal column stimulation was undertaken in 10 patients referred to the Pain Relief Clinic for management of otherwise intractable angina pectoris. All patients were on maximal medical therapy and were determined to be unsuitable for coronary artery revascularization by the referring cardiologists. Dorsal column stimulation was beneficial in all patients by decreasing the frequency and severity of anginal attacks. The mechanism of action of dorsal column stimulation in this condition is uncertain.

                Author and article information

                S. Karger AG
                February 2003
                24 February 2003
                : 99
                : 1
                : 20-24
                aMultidisciplinary Pain Centre, Sahlgrenska University Hospital/Östra, bInstitute of Clinical Neuroscience, Stroke Research Unit, cCardiovascular Centre, Sahlgrenska University Hospital, Göteborg, Sweden
                68447 Cardiology 2003;99:20–24
                © 2003 S. Karger AG, Basel

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                Page count
                Tables: 4, References: 27, Pages: 5
                General Cardiology


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