Device-Based Therapies for Refractory Angina

A substantial proportion of patients with ischemic heart disease continue to experience recurrent or persistent angina despite optimized medical therapy and prior revascularization, highlighting the need for novel and effective treatment strategies. Device-based therapies have emerged as promising options to address this unmet clinical need. Among these, the Coronary Sinus Reducer™ (CSR) has gained particular attention, supported by randomized trials and registries demonstrating improvements in angina symptoms and quality of life, with a favorable safety profile. However, a disconnect between symptomatic relief and objective measures of myocardial perfusion has been noted, suggesting that the underlying mechanisms remain incompletely understood. Beyond the CSR, other device-based approaches-such as enhanced external counterpulsation, neuromodulation, and shockwave therapy-are either approved or under investigation. This review explores the current landscape of device-based therapies for angina, focusing on the evidence supporting the CSR and other device-based interventions. We discuss pathophysiological mechanisms, clinical outcomes, and future research directions aimed at optimizing therapeutic efficacy. Integrating patient-reported outcomes with physiological and imaging assessments will be essential to refine indications and improve long-term results. Device-based therapies represent a developing frontier in angina management, with the potential to improve outcomes in patients with persistent symptoms despite optimal medical and interventional therapy.