A recent letter published in the Journal of the American College of Cardiology calls for greater recognition of the Coronary Sinus Reducer (CSR) as an innovative therapy for patients with refractory angina. The response comes after an earlier review appeared in the journal that discusses a patient-centered approach to managing stable angina that omitted discussion of the CSR despite its popularity and demonstrated efficacy. “The CSR is a recommended therapy by the 2019 European Society of Cardiology (ESC) guidelines for the treatment of angina in patients with stable coronary artery disease,” said the letter’s authors, led by Shmuel Banai, MD, from Tel Aviv Medical Center in Israel. Angina management The review, led by Rocco A. Montone, MD, from the Catholic University of the Sacred Heart in Rome, discussed optimizing stable angina management from a patient-centered viewpoint. Focusing on angina pectoris, the review team said the condition could arise from obstructive coronary artery disease (CAD) or in the absence of significant CAD. Functional mechanisms may be involved in determining angina both in obstructive CAD and in ischemia with non-obstructed coronary arteries, they added. The review went on to detail the complimentary roles of revascularization and medical therapy in achieving optimal outcomes for patients with angina. The review concludes with the observation that management of angina was shifting toward a more personalized approach, moving away from the traditional one-size-fits-all strategy. CSR overlooked Despite the optimism and promise for the future, Dr. Banai and his fellow authors questioned why the review team ignore what appears to be a “novel, safe, and effective therapy for stable angina.” “[It is] a therapy that is increasingly used clinically in many catheterization laboratories, mainly in Europe,” they added. “We wonder why the authors completely ignored…the safe and effective therapy for patients with chronic angina that is refractory to medical and interventional therapies.” Supportive evidence In support of their objections, the letter highlights a series of trials that demonstrates coronary sinus (CS) narrowing with the CSR as a safe and effective therapy for patients experiencing refractory angina and obstructive coronary artery disease (CAD). The authors add that in the ischemic heart, narrowing of the CS is shown to reduce coronary vascular resistance, improve coronary flow reserve, and improve perfusion to the ischemic subendocardium. Further evidence comes in the form of recently published data that show that CS narrowing with the CSR improves the quality of life and relieves angina in patients with and without obstructive CAD by improving coronary microvascular function. Source: Banai S, Lerman A, Verheye S. The Reducer Is a Novel, Safe, and Effective Therapy to Optimize the Management of Patients With Stable Angina. J Am Coll Cardiol. 2024;84 (Article in Press). Image Credit: 220 Selfmade studio – stock.adobe.com