Identifying people with angina who need extra rehabilitation support

Dr Carl Bickler

How are we doing in Lothian?

Angina in Lothian

SIGN guideline

All post-myocardial

infarction and revascularisation patients should

receive rehabilitation

Lothian

All post-myocardial

infarction and surgical patients receive a formal

rehabilitation programme

Angina in Lothian

SIGN guideline

All new patients with angina should be

considered for rehabilitation

Lothian

Patients having an angioplasty for angina don’t routinely receive

rehabilitation

Programmes exist for angina…….but few are considered

Angina in Lothian

SIGN guideline

All patients with existing CHD who

have a step-change in their condition should have their

rehabilitation needs assessed

Lothian

Patients with existing CHD can

have their rehabilitation

needs met …….

…..but are rarely referred

So who is missing out?

Angina in Lothian

• new angina patients who are treated by angioplasty

• new angina patients who are medically managed

• chronic angina with worsening symptoms• patients discharged with unstable

angina.

Coming soon …

NHS QIS clinical standards for CHD –

Patients with the following conditions or having had these procedures, who are assessed and identified as needing cardiac rehabilitation, at the time of diagnosis or procedure, are offered a menu-based programme:

• acute coronary syndrome• coronary by-pass surgery (elective and urgent)• angioplasty (elective and urgent)• patients with new onset or worsening angina

who have not had one of the above• heart valve surgery

Coming soon …

NHS QIS clinical standards for CHD –

Patients with the following conditions or having had these procedures, who are assessed and identified as needing cardiac rehabilitation, at the time of diagnosis or procedure, are offered a menu-based programme:

• acute coronary syndrome• coronary by-pass surgery (elective and urgent)• angioplasty (elective and urgent)• patients with new onset or worsening angina

who have not had one of the above• heart valve surgery

The good news is ….

We have the infrastructure to provide for all groups

Principles of the angina pathway

Angina pathway

• all patients with angina should be given basic written information eg CHSS booklet

• all patients should subsequently be assessed for rehabilitation

•secondary prevention clinics•assessment tool

• those with ongoing needs should receive rehabilitation input

•angina manual•angina management programme•individualised input.

Aims:• identify any factors that need

emergency or urgent intervention• identify rehabilitation needs that

require an intervention• angina versus non angina-related

needs• inform decision on course of action

– non-intervention– in-house intervention, and/or– referral.

Assessment tool

Pilot of assessment tool • 5 practices - started November 2008• tool

•symptoms•quality of life (fitness, activity,

feelings, support)•beliefs about angina

• referral options•A&E or emergency admission•rapid access chest pain clinic•cardiology outpatient clinic•cardiac rehabilitation

• results autumn 2009.

Happening now…

Next steps…

• evaluation of Angina Plan approach•within Cardiac Rehabilitation Lothian

•in general practice• roll-out across primary care?• support development of training courses

for practice nurses.