“No option” patients for coronary revascularization: the only thing that is constant is change

Refractory angina pectoris (RAP) associated with myocardial ischemia is a common medical condition, a major cause of patient morbidity and a growing public health burden that affects millions of patients worldwide (1-4). Importantly, despite recent advancements in patient care, there is lack of convincing evidence regarding reduction in both ischemia burden and mortality in this challenging patient population (4). Moreover, a significant proportion of these patients have no revascularization options despite improved interventional procedures and techniques. Patients with RAP are also more frequently hospitalized than controls, often undergoing multiple medical procedures, increasing the economic burden to the healthcare system (5).