Management of Stable Angina

SIGN 96

Angina Patient JourneyAngina Patient Journey

Diagnosis and Assessment

Pharmacological management

Interventional cardiology and cardiac surgery

Patient issues and follow up

Presentation

Chest pain evaluation service

Drug intervention to prevent new vascular events

Stable angina and non-cardiac surgery

Psychological and cognitive issues

Patient presents with chest pain likely to be due to stable angina

Consider characteristics of pain and associated features

Detailed clinical examination

Consider need for early referral

Refer for confirmation of diagnosis to chest pain service

Coronary angiography

Exercise tolerance test or Myocardial perfusion scintigraphy if

unable to exercise or pre existing ECG abnormalities

12 Lead ECG Measure Hb, TSH,

TC, RBS

C

B

C

B

Care of patients with suspected angina

Confirm diagnosis and assess severity of CHD

Use chest pain evaluation service with earliest appointmentB

Early access to angiography and coronary artery bypass surgery may reduce the risk of adverse cardiac events and

impaired quality of lifeC

Alleviation of angina symptoms

Beta blockers first line therapy

Inadequate control of symptoms – add a calcium channel

blocker

Sublingual GTN tablets or spray for immediate relief

& before activities known to bring on angina

A

A

A

If intolerant of beta blockers treat with a rate limiting

calcium channel blocker, long acting nitrates or nicorandil

A

Consider referral to a cardiologist if symptoms not controlled on maximum therapeutic doses of two drugs

Consider ACEI in all patients with stable angina

Meta-analysis of 6 RCTs – 33,500 patients – CHD and preserved LVSD

Meta-analysis of HOPE, EUROPA and PEACE data – 29,805 patients

ACEI significantly reduce all cause and cardiovascular mortality

Prevention of new vascular events

A

Long-term standard aspirin therapy

Long-term statin therapy

A A

Consider for revascularisation

For symptomatic benefit

PCI (CABG if unsuitable)

Left main stem

disease

Triplevessel

disease

CABG

To improve prognosis

PCI

A

A A

Medical therapy failing to control symptoms

One or two vessel

disease

Revascularisation by CABG

Advise that cognitive decline is common in first 2 months after

surgery

Screen for anxiety and depression before, and one year after surgery

Psychological issues

Manage appropriately

For those at higher risk, older, other

atherosclerosis and/or existing cognitive

impairment take into consideration when

evaluating revascularisation

options

Implement rehabilitation

programme after revascularisation

Off-pump CABG should not be used

as the basis to protect against

cognitive declineB

D

D

D

A

Impact of angina on quality of life

Improving symptom Control

Symptoms uncontrolled and reduced physical functioning despite

optimal medical therapy

Assess impact of angina on mood, quality of life, and

function to monitor progress and inform treatment decisions

Consider Angina Plan

Effect of health beliefs

Assess patients beliefs about angina

when discussing management of risk factors and how to

cope with symptoms

Consider interventions to alter health beliefs

based on psychological

principles Consider Angina Plan

Psychological issues

B

D

B

D

Patients with refractory angina may benefit from an educational and rehabilitative approach based on cognitive behaviour principles prior to

considering invasive treatment

D

Patients with CHD undergoing non-cardiac surgery (1)

Use risk assessment tool to quantify

risk of serious cardiac events

Further investigate those with

co-morbidities undergoing high risk surgery with either anexercise tolerance test

or coronary angiography

Make a pre-op objective assessment of functional

capacity before major surgery

Good teamwork and good communication

between surgeon, anaesthetist/physician, cardiologist and patient

is required to agree a risk reduction strategy

B

B D

If surgery required after PCI

Pre-operative revascularisation

Only perform pre-operatively if cardiac symptoms unstable

and/or CABG justified on basis of

long term outcome

D

Continue dual antiplatelet therapy as far as possible

Patients with CHD undergoing non-cardiac surgery (2)

D

Pre-operativebeta blocker if

undergoing high or intermediate risk

non-cardiac surgery in those who are at high risk of cardiac

events

Only withhold low dose aspirin if high related

bleeding risk

Start low dose aspirin as soon as possible after

surgery if withdrawn preoperatively

Continue pre-existing beta blocker in peri-

operative period

Start statins before surgery

Continue through

perioperative periodB

D

A

C

Patients with CHD undergoing non-cardiac surgery (3)

D

Long term follow up

Angina symptoms

Coronary heart disease confirmed

Arrange long term structured follow up in primary care

A