Dtsch Arztebl Int. 2026 Dec 11;123(25):arztebl.m2026.0175. doi: 10.3238/arztebl.m2026.0175. Online ahead of print.

ABSTRACT

BACKGROUND: Coronary heart disease (CHD) is among the more common cardiovascular diseases, affecting 4.7 million people in Germany alone. As many as 20% of patients with CHD still suffer from angina pectoris despite appropriate antianginal therapy and revascularization. Refractory angina pectoris reduces quality of life and increases mortality. In this review, we describe therapeutic strategies and the clinical evidence underlying them.

METHODS: This review is based on publications up to December 2025 retrieved through a selective search in Medline/PubMed for RCTs, before-and-after studies, and guidelines on the treatment of refractory angina pectoris.

RESULTS: The treatment of refractory angina pectoris begins with reducing risk factors, optimizing pharmacotherapy, and considering revascularization for functionally significant coronary stenosis. If these treatment options have been exhausted, the implantation of a sinus reducer may be considered, as recommended in the European guidelines (recommendation grade IIb). The evidence for this is derived from randomized trials and from multiple registry and observational studies. In the sham-controlled COSIRA trial, which involved 104 patients, an improvement in angina symptoms by at least two classes on the Canadian Cardiovascular Society (CCS) grading scale was observed in 35% of patients six months after implantation, compared with 15% in the control group. The multicenter ORBITA-COSMIC trial, which involved 51 patients, also yielded a reduction in daily angina pectoris compared with the control group (OR 1.40; 95% CI: [1.08; 1.83]). Potential complications include migration, embolization of the reducer, and coronary sinus perforation or dissection in 1-2% of patients. These events are only rarely clinically significant.

CONCLUSION: The sinus reducer may improve symptoms in selected patients, but the reported periprocedural complications and limited evidence to date on long-term outcomes should enter into the decision whether to provide this treatment to the individual patient.

PMID:42876223 | DOI:10.3238/arztebl.m2026.0175