British Medical Bulletin 2001;59: 269–78 The British Council 2001

Neuromodulation is the use of therapies which alter the relationship between the heart, its autonomic innervation and the central nervous system with the objective of reducing the ischaemic burden and diminishing the perception of angina. Despite rapid innovations in percutaneous and surgical revascularisation techniques, increasing numbers of refractory angina patients are presenting to cardiologists with advanced coronary disease, which is unsuitable for further revascularisation. Such patients are often severely disabled by chronic angina pectoris, which often correlates poorly with the degree of observable ischaemia. It is with the background of this burgeoning group of patients, ‘refractory ’ to revascularisation, that has led to increasing interest in the alternative strategies of neuromodulation. Neuromodulation owes its origins to Melzack and Wall’s gate theory of pain1 that predicted that stimulation of vibratory afferent nerves would reduce or gate the transmission of pain traffic relaying through the cord at the same point. Transcutaneous electrical nerve stimulation (TENS)2 was specifically designed to make use of this predicted effect and was used to treat a variety of pain conditions, before it was shown to be effective in angina. Spinal cord stimulation (SCS) was also used to good effect in non-cardiac pain conditions before being found to be effective in relieving angina in a patient implanted for cancer pain control. The UK Pain Society Angina Special Interest Group and the Angina Specia