Angina: refractory: transmyocardial revascularisation reduced angina symptoms, but increased heart failure

Clinical bottom line (level 1b)

  1. Patients with medically-refractory angina who received transmyocardial laser revascularisation and continued medication compared with continued medication alone were less likely to develop unstable angina (NNT = 3 at 12 months) , and more likely to have an improvement in symptoms (NNT = 2 at 12 months) .
  2. Patients given transmyocardial revascularisation were more likely to develop heart failure (NNH = 6 at 12 months) .
  3. There was no clear difference in mortality between the two groups.
Burkhoff et al: Lancet 1999; 354 : 885-890
Expires January 2004

The study

Single-blinded concealed randomised trial with intention-to-treat
Setting: 16 acute hospitals, USA

182 patients (aged 36 to 78; mean 64, 91% male) with refractory angina (Canadian Cardiovascular Society Angina score III or IV for at least 21 days) and incomplete response of other therapies.

Excluded if
  • eligible for percutaneous or surgical revascularisation
  • LV ejection fraction < 30%
  • no reversible ischaemia
  • no protected areas of myocardium (perfused by unobstructed blood flow through a major vessel)

Control Group: (n = 90, 83 analysed): continued medication
Experimental Group: (n = 92, 85 analysed): transmyocardial laser revascularisation and continued medication

92% followed for 12 months

The evidence

Outcome Time to outcome CER EER RRR
(95% CI)		 ARR
(95% CI)		 NNT
(95% CI)
death 12 months 9
(10.0%)		 5
(5.43%)		 46%
(-56% to 81%)		 4.57%
(-3.17% to 12.3%)		 22
(NNT = 32 to infinity;
NNH = 8 to infinity)
unstable angina requiring hospitalisation 4 months 69
(76.7%)		 37
(40.2%)		 48%
(31% to 60%)		 36.5%
(23.2% to 49.7%)		 3
(2 to 4)
heart failure or left ventricular dysfunction 12 months 10
(11.1%)		 25
(27.2%)		 -150%
(-380% to -25%)		 -16.1%
(-27.2% to -4.89%)		 -6
(-20 to -4)
fall in CCSA score by 2 or more classes 12 months 8
(11.0%)		 47
(61.0%)		 460%
(180% to 1000%)		 50.1%
(37.0% to 63.1%)		 2
(2 to 3)

  • 77 patients treated with transmyocardial revascularisation and 73 patients on medication were assessed for angina at 12 months.

Comments

  1. Patients undergoing transmyocardial revascularisation received 9 to 42 channels (median 18)

Citation

  1. Burkhoff D, Schmidt S, Schulman SP, et al: transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomised trial (ATLANTIC). Lancet 1999; 354 : 885-890
Search Terms: from ACP Journal Club other articles noted
Contributor: Chris Ball, January 2002
Reviewer:

Clinical Question.
Patient medically-refractory angina
Intervention or Exposure transmyocardial laser revascularisation and continued medication
Comparison continued medication
Outcome death, angina, heart failure