High thoracic epidural analgesia for relief of coronary ischemia syndrome without cardiac surgery

Sympathetic blockade for the control of ischemia in patients with coronary atherosclerotic disease has been controversial and is questioned as to its benefit in comparison to other pharmacologic and interventional therapies available. The main concern is that thoracic analgesia (TEA) only blocks pain and the patient continues to be ischemic. Coronary blood flow is dependent on both β- and α-adrenergic input. In normal patients, there is a balance of these inputs, so the heart is adequately perfused. In the case of coronary artery disease, the vessels no longer respond normally to circulating catecholamines. Even though β-blockade is used, α-blockade is not tolerated by patients due to hypotension which can decrease coronary perfusion pressures. The growing body of experience and literature confirms that there are significant physiological changes rather than a placebo effect with TEA. Its use can preferentially shunt blood to endocardium, dilate stenotic vessels, favorably balance the determinants of myocardial supply and demand, allow increased exercise tolerance, decrease catecholamine levels, and improve quality of life. Thus, TEA is a viable option to control intractable angina when the usual modalities have failed.

Keywords: Thoracic epidural, Sympathetic blockade, Intractible angina, Bupivacaine infusions, Dupen catheter, Epiport, Cardiac ischemic physiology