Angina pectoris (literally "chest tightness") refers to pain in the chest area accompanied by a characteristic feeling of tightness. The cause is a disease of the coronary arteries, which are usually severely narrowed due to arteriosclerosis, resulting in insufficient blood flow and oxygen supply to the heart muscle. If the pain persists despite drug or surgical treatment, the condition is called refractory angina pectoris (RAP). A neuromodulation procedure called spinal cord stimulation is available as a treatment for this distressing pain syndrome. Find out here how we can help you with spinal cord stimulation.

9.3 out of 10
top rating in recommendation by our patients
specifically trained pain nurses
functional interventions per year

How is angina pectoris classified?

Angina pectoris (AP) can be divided into different severity levels according to the Canadian Cardiovascular Society (CCS) *:

  • Grade I: AP with great effort
  • Grade II: AP with moderate effort (walking or climbing stairs quickly, walking uphill)
  • Grade III: AP with minor effort (climbing stairs)
  • Grade IV: AP symptoms even at rest

If symptoms occur for longer than 3 months and or persist despite medication, interventional procedures (angioplasty) or surgical procedures (bypass surgery), they are termed chronic. The condition is then known as refractory angina pectoris (RAP).

How is angina pectoris treated?

Conventional therapy

Standard therapy for angina pectoris, or underlying coronary artery disease, involves the following:

  • elimination of individual risk factors
  • drug therapy
  • surgery to restore vascular perfusion (bypass, stents, angioplasty)


Patients with grade III or IV angina pectoris who have exhausted conventional therapies and continue to suffer from persistent pain are considered to have refractory angina pectoris. In this case, a neuromodulation procedure called spinal cord stimulation (SCS) is a recommended treatment option.

Spinal cord stimulation can not only relieve persistent pain, but also significantly improve blood flow to the heart and thus quality of life. Therapy of refractory angina pectoris with spinal cord stimulation is safe and reversible and is recommended by the European Society of Cardiology and others *.

More about spinal cord stimulation

How does spinal cord stimulation work?

The exact way in which spinal cord stimulation works has not yet been conclusively clarified. A variety of mechanisms appear to be involved: on the one hand, the regulation of pain signals in the heart, on the other hand, the modulation of the sympathetic autonomic nervous system may have an effect. Finally, the effects lead to fewer arrhythmias and improved blood flow to the heart*.

Studies on spinal cord stimulation

There are several progressive randomized trials as well as a systematic review article * and a meta-analysis * that have examined the effects of spinal cord stimulation. In summary, spinal cord stimulation has shown to produce a statistically significant reduction in pain intensity.

Additionally, the frequency of pain related symptoms decreases, so that the intake of nitroglycerin can be reduced.

For patients undergoing spinal cord stimulation, an improvement of more than 2 grades can be achieved according to the CCS scheme, which significantly improves the overall quality of life of the affected individuals.


  1. Mannheimer C, Augustinsson L, Carlsson C, Manhem K, Wilhelmsson C. Epidural spinal electrical stimulation in severe angina pectoris. Heart. 1988;59(1):56-61.

  2. Campeau L. Letter: Grading of angina pectoris. Circulation. 1976;54(3):522-523.

  3. Knuuti J. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). Russian Journal of Cardiology. 2020;25(2):119-180.

  4. Coote J, Chauhan R. The sympathetic innervation of the heart: Important new insights. Autonomic Neuroscience. 2016;199:17-23.

  5. Tsigaridas N, Naka K, Tsapogas P, Herios Pelechas E, Damigos D. Spinal cord stimulation in refractory angina. A systematic review of randomized controlled trials. Acta Cardiologica. 2015;70(2):233-243.

  6. Pan X, Bao H, Si Y, Xu C, Chen H, Gao X, Xie X, Xu Y, Sun F, Zeng L. Spinal Cord Stimulation for Refractory Angina Pectoris: A Systematic Review and Meta-analysis. Clin J Pain. 2017 Jun;33(6):543-551.