Transcript Slide set

Stable angina
Implementing NICE guidance
July 2011
NICE clinical guideline 126
What this presentation covers
Background
Epidemiology
Scope
Key priorities for implementation
Further recommendation areas
Costs and savings
Discussion
Find out more
Background
Stable angina is:
• pain or constricting discomfort, often in the front of the
chest
• caused by restriction of blood flow and oxygen to the
heart muscle
• brought on by physical exertion or emotional stress
• a chronic medical condition associated with incidence
of acute coronary events and increased mortality.
Management aims to:
• stop or minimise symptoms
• improve quality of life and long-term morbidity and
mortality.
Epidemiology
• Around 8% of men and 3% of women aged 55–64
currently have or have had angina.
• The figures for men and women aged 65–74 are
around 14% and 8% respectively.
• It is estimated that almost 2 million people in England
currently have or have had angina.
• Angina has a significant impact on quality of life.
Scope
The recommendations in this guideline relate only to
adults (18 years and older) who have been diagnosed
with stable angina due to atherosclerotic disease.
Groups not covered are people with
• recent onset of chest pain or discomfort
• acute coronary syndrome
• angina type pain likely due to non cardiac disease
or associated with other types of heart disease
Key priorities for implementation
The areas identified as key priorities for implementation
are:
• Information and support for people with stable angina
• Anti-anginal drug treatment
• Investigation and revascularisation
Information and support for
people with stable angina
Explore and address issues according to the person’s
needs, which may include:
• self-management skills such as pacing their activities
and goal setting
• concerns about the impact of stress, anxiety or
depression on angina
• advice about physical exertion
including sexual activity.
Anti-anginal drug treatment –
general recommendations
• Offer people optimal drug
treatment for the initial
management of stable angina.
• Optimal drug treatment consists of:
- one or two anti-anginal drugs as necessary
plus
- drugs for secondary prevention of
cardiovascular disease.
Anti-anginal drug treatment –
drugs for treating stable
Offer either a beta blocker or calcium channel
angina
blocker as first-line treatment for stable angina
Beta blocker or calcium channel blocker not
tolerated
Symptoms not satisfactorily controlled
Symptoms not satisfactorily controlled on two
anti-anginal drugs and the person is waiting for
revascularisation or revascularisation is not
considered appropriate
Consider switching to
the other option
Consider either switching
to the other option or
using a combination of the
two
Consider adding a third
anti-anginal drug
Do not:
• offer a third anti-anginal drug when stable angina is controlled with two
• routinely offer anti-anginal drugs other than beta blockers or calcium channel blockers
as first-line treatment for stable angina.
Investigation and
revascularisation (1)
When symptoms are not satisfactorily controlled with
optimal medical treatment: 1
• Consider CABG or PCI.
• When either procedure would be appropriate,
explain the risks and benefits of PCI and CABG for
people with anatomically less complex disease. If
no preference is expressed, take account of the
evidence that suggests PCI may be the more cost
effective procedure, when selecting the course of
treatment.
Investigation and
revascularisation (2)
When symptoms are not satisfactorily controlled with
optimal medical treatment: 2
When either procedure would be appropriate, take into
account the potential survival advantage of CABG over PCI
for people with multivessel disease who:
– have diabetes or
– are over 65 years or
– have anatomically complex three-vessel disease, with
or without involvement of the left main stem.
Investigation and
revascularisation (3)
When symptoms are not satisfactorily controlled with
optimal medical treatment: 3
Consider the relative risks and benefits of CABG
and PCI using a systematic approach to assess
severity and complexity of coronary disease, in
addition to relevant clinical factors and
comorbidities
Investigation and
revascularisation (4)
When symptoms are not satisfactorily controlled with
optimal medical treatment: 4
Ensure there is a regular multidisciplinary team meeting to
discuss treatment strategy for:
• people with left main stem or anatomically complex three-vessel
disease
• people in whom there is doubt about the best method of
revascularisation because of the complexity of the coronary
anatomy, the extent of stenting required or other relevant
clinical factors and comorbidities.
Investigation and
revascularisation (5)
When symptoms are not satisfactorily controlled with
optimal medical treatment: 5
• If revascularisation is appropriate, explain to the
person:
- the main purpose of revascularisation is to
improve the symptoms of stable angina
- the risks and benefits of the two procedures.
Investigation and
revascularisation (6)
When symptoms are satisfactorily controlled with
optimal medical treatment: 1
• Discuss the following with people whose symptoms are
satisfactorily controlled with optimal medical
management:
• prognosis
• likelihood of having left main stem disease or
proximal three-vessel disease
• availability of CABG to improve prognosis in a
specific subgroup
• process and risks of investigation
• benefits and risks of CABG.
Answer to each box must
be ‘YES’ to proceed
Investigation and
revascularisation (7)
When symptoms are satisfactorily controlled with
optimal medical treatment: 2
Discuss prognosis, likelihood of having left main stem or proximal three-vessel
disease, the process and risks of investigation, the benefits and risks of CABG
with person with stable angina and check they are happy to proceed?
Consider a functional or non-invasive anatomical test to identify people who
might gain a survival benefit from surgery?
Tests indicate extensive ischemia or likelihood of left main stem or proximal
three-vessel disease?
Revascularisation acceptable and appropriate?
Consider CABG if coronary angiography indicates left main stem or proximal
three-vessel disease
‘Do not’ recommendations
Do not :
x exclude people from treatment based on their age
x investigate or treat symptoms differently in men and
women or in different ethnic groups
x offer vitamin or fish oil supplements
x offer TENS, EECP or acupuncture
x routinely offer drugs for secondary prevention of
cardiovascular disease to people with suspected
cardiac syndrome X.
Costs and savings
The guideline on stable angina is unlikely to result in a
significant change in resource use in the NHS. However,
implementation of the guideline may result in the following:
• small increases in cost involving multidisciplinary team
meetings
• reduced need for revascularisation when symptoms are
satisfactorily controlled with optimal medical treatment
• increased awareness of newer more expensive drugs
Discussion
• Currently what is our treatment and management
strategy for stable angina?
• Does our management strategy need to change to
bring it in line with this NICE guidance? If it does need
to change, how will we do this?
• How can we ensure our multidisciplinary team
meetings meet the requirements identified in the
guideline?
NHS
Evidence
Visit NHS Evidence
for the best
available evidence
on all aspects of
cardiovascular
disease
Click here to go to
the NHS Evidence
website
Find out more
Visit www.nice.org.uk/guidance/CG126 for:
• the guideline
• the quick reference guide
• ‘Understanding NICE guidance’
• costing statement
• audit support
• baseline assessment tool
• factsheet on revascularisation for stable angina
• chest pain algorithm
The NICE stable angina quality standard published
in August 2012
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