DISCUSSION
RAP, myocardial ischemia, infections, dislocation
REFRACTORY ANGINA PECTORIS, ADVERSE EVENTS, ADVERSE EVENT, MYOCARDIAL ISCHEMIA, INFECTIONS, CHRONIC PAIN
The SCRAP trial will be conducted in a large specialized hospital in the Netherlands (Catharina Hospital, Eindhoven). In the Netherlands, the “National Health Care Institute” evaluates certain aspects of our health care system to determine if a treatment modality is effective and should be part of insured health care. In November 2019, the National Health Care Institute evaluated the treatment modality neuromodulation in patients with chronic pain, including patients with RAP. The report concluded that, based on the available literature (June 2018), spinal cord stimulation should not be considered as an effective treatment modality in patients with refractory angina pectoris and should therefore no longer be part of insured health care in the Netherlands.The decision to use changes in myocardial ischemia, measured with myocardial perfusion PET scanning, as primary endpoint is based on the afore mentioned report of the National Health Care Institute. An important comment in the report was that evidence of reduction in myocardial ischemia is currently missing, which led to the formulation of the chosen primary endpoint.The choice of 6 months SCS treatment is based on previous research that has shown that changes can be seen in myocardial blood flow (using PET) after 3–6 weeks of SCS therapy.An important concern voiced in previous literature is the risk of adverse events related to the spinal cord stimulator implantation in general. Adverse events range from lead dislocation to device related infections with a reported incidence of up to 40%.