Transcript Document

Management of
Stable Angina
SIGN 96
Angina Patient Journey
Patient issues
and follow up
Interventional
cardiology and
cardiac surgery
Psychological and
cognitive issues
Stable angina and
non-cardiac surgery
Drug intervention
to prevent new
vascular events
Pharmacological
management
Chest pain
evaluation
service
Diagnosis
and
Assessment
Presentation
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

C
12 Lead ECG
Measure Hb, TSH,
TC, RBS 
B
Refer for confirmation of
diagnosis to chest pain service
C
Coronary
angiography

Exercise tolerance test or
Myocardial perfusion scintigraphy if
unable to exercise or pre existing
B
ECG abnormalities
Care of patients with suspected angina
Confirm diagnosis and assess severity of CHD
B
Use chest pain evaluation service with
earliest appointment
Early access to angiography and coronary artery bypass
surgery may reduce the risk of adverse cardiac events and
impaired quality of life
C
Alleviation of angina symptoms
A
A
Beta blockers first line therapy
Sublingual GTN tablets or
spray for immediate relief
& before activities known to
bring on angina
Inadequate control of
symptoms – add a
A
calcium channel
blocker
If intolerant of beta blockers
treat with a rate limiting
A
calcium channel blocker, long
acting nitrates or nicorandil
Consider referral to a cardiologist if symptoms not controlled
on maximum therapeutic doses of two drugs

Prevention of new vascular events
A
Long-term standard
aspirin therapy
A
A
Long-term
statin therapy
Consider ACEI in all patients with stable angina
ACEI significantly reduce all cause
and cardiovascular mortality
Meta-analysis of 6 RCTs – 33,500 patients – CHD
and preserved LVSD
Meta-analysis of HOPE, EUROPA and PEACE data
– 29,805 patients
Consider for revascularisation
One or two
vessel
disease
Left main
stem
disease
To improve
prognosis
Medical therapy failing
to control symptoms
For symptomatic
benefit
A
PCI
(CABG if unsuitable)
Triple
vessel
disease
A
CABG
A
PCI
Revascularisation by CABG
Psychological issues
Advise that cognitive
decline is common in
first 2 months after
surgery
B
D
For those at higher
risk, older, other
atherosclerosis and/or
existing cognitive
impairment take into
consideration when
evaluating
revascularisation
options
D Screen for anxiety and
depression before, and
one year after surgery
D
Manage
appropriately
Implement
rehabilitation
programme after
revascularisation
A Off-pump CABG
should not be used
as the basis to
protect against
cognitive decline
Psychological issues
Impact of angina
on quality of life
Improving symptom
Control
Effect of health
beliefs
D
Assess impact of
angina on mood,
quality of life, and
function to monitor
progress and inform
treatment decisions
D
Symptoms uncontrolled
and reduced physical
functioning despite
optimal medical therapy
B Consider Angina Plan
D
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
B
psychological
principles
Consider Angina Plan
Patients with refractory angina may benefit from an educational and
rehabilitative approach based on cognitive behaviour principles prior to
considering invasive treatment
Patients with CHD undergoing
non-cardiac surgery (1)
Use risk assessment
tool to quantify
risk of serious cardiac
events
B
Further investigate
those with
B
co-morbidities
undergoing high risk
surgery with either an
exercise tolerance test
or coronary
angiography
Make a pre-op objective
assessment of functional
capacity before major
surgery
D
Good teamwork and
good communication
between surgeon,
anaesthetist/physician,
cardiologist and patient
is required to agree a 
risk reduction strategy
Patients with CHD undergoing
non-cardiac surgery (2)
Pre-operative revascularisation
Only perform pre-operatively if
cardiac symptoms unstable
D
and/or
CABG justified on basis of
long term outcome
If surgery required after PCI
D
Continue dual
antiplatelet therapy
as far as possible
Patients with CHD undergoing
non-cardiac surgery (3)
A
Pre-operative
beta 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
C
bleeding risk
D
Continue pre-existing
B beta blocker in perioperative period
Start low dose
aspirin as soon
as possible after
surgery if withdrawn
preoperatively
D
Start statins
before surgery
Continue
through
perioperative
period

Long term follow up
Angina symptoms
Coronary heart disease confirmed
A
Arrange long term structured
follow up in primary care