Angina: refractory: transmyocardial laser revascularisation improved symptoms without clearly increasing mortality

Clinical bottom line (level 1b)

  1. Patients with refractory angina who received transmyocardial laser revascularisation compared with optimal medical therapy alone were more likely to have an improvement in functional status (NNT = 2 at 12 months) .
  2. There was no clear difference in mortality between the two groups.
Aaberge et al: Journal of the American College of Cardiology 2000; 35 : 1170-1177
Expires October 2003

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: university hospital, Norway

100 patients (aged mean 62, 72% male) with refractory angina (NYHA class III or IV), who were not candidates for PTCA or CABG. due to peripheral obstructions in the coronary arteries.

Excluded if
  • inability to perform study tests
  • conditions precluding thoracic surgery
  • aged > 75
  • left ventriular ejection fraction < 30%
  • versible ischaemia not demonstrated
  • overt heart failure

Control Group: (n = 50, 50 analysed): optimal medical therapy
Experimental Group: (n = 50, 50 analysed): optimal medical therapy plus transmyocardial revascularization with CO 2 laser

100% followed for 12 months

The evidence

Outcome Time to outcome CER EER RRR
(95% CI)		 ARR
(95% CI)		 NNT
(95% CI)
improvement of 2 or more functional classes 12 months 0
(0.0%)		 19
(38.0%)		 %
(% to %)		 38.0%
(24.5% to 51.5%)		 3
(2 to 4)
improvement of 1 or more functional classes 12 months 11
(22.0%)		 35
(70.0%)		 -220%
(-450% to -83%)		 48.0%
(30.9% to %)		 2
(2 to 3)
death 12 months 4
(8.00%)		 6
(12.0%)		 -50%
(-400% to 55%)		 -4.00%
(-15.7% to 7.73%)		 -25
(NNT = 13 to infinity;
NNH = 6 to infinity)

Comments

  1. The study is too small to show any difference in mortality between the two groups.
  2. Perioperative mortality for transmyocardial revascularisation was 4%.

Citation

  1. Aaberge L, Nordstrand K, Dragsund M, et al: transmyocardial revascularisation with CO2 laser in patients with refractory angina pectoris: clinical results from the Norwegian randomised trial. Journal of the American College of Cardiology 2000; 35 : 1170-1177
Search Terms: from other articles noted in ACP Journal Club
Contributor: Chris Ball, October 2001
Reviewer:

Clinical Question.
Patient refractory angina
Intervention or Exposure transmyocardial laser revascularisation
Comparison optimal medical therapy
Outcome death, improvement in angina