SIGN GUIDELINE 96

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SIGN GUIDELINE 96

• Management of stable angina
• Feb 2007

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Prevalence

• Scotland
• 5.1 male 4 female (55-64 years)
• 6.7 male 6.8 female (65-74 years)

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What is angina?

• Clinical syndrome of chest pain of pressure
  precipitated by exercise or emotional distress ie
  increase in myocardial oxygen demands
• Predictable onset and relieved by rest or GTN.
• NB Guideline specific to angina resulting from
  atherosclerotic CHD

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Establishing diagnosis

• Hx
• type of pain
• location
• relation to exertion
• relieved by rest/GTN
• duration
• (Atypically SOB, burping)

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Severity

• Can be graded using scale devised by Canadian
  Cardiovascular Society
• Class 1 - ordinary activity such as
  walking/climbing stairs does not precipitate
  angina
• Class 2 - angina precipitated by emotion, cold
  weather, meals or walking up the stairs
• Class 3 - marked limitations in ordinary physical
  activity
• Class 4 - inability to carry out any physical
  activity without discomfort, anginal symptoms may
  be present at rest

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Risk Factors

• Smoking
• Hypertension
• Family Hx
• Hypercholest.
• DM

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Other factors to evaluate

• BMI
• Murmurs
• Hb
• TFTs
• Depression/social isolation
• Physical Activity

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Diagnostic Tools

• Baseline ECG
• Exercise ECG
• Myocardial Perfusion Scintigraphy
• Angiography
• Others MRI, multislice CT

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What should GP do?

• Hx
• Ex
• BP
• HB/TFTs/Cholesterol and Glc
• Ref to cardiology O/P for further assessment
  urgent if new onset or worsening in stable
  symptoms

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Non-cardiac Chest Pain

• Important to make this diagnosis early to reduce
  anxiety/distress/unnecessary hospital contact
• If diagnosis uncertain clinicians shouldnt give
  impression of angina because it may be difficult
  to change health beliefs even if investigations
  exclude diagnosis at a later date

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Pharmacology

• Betablockers
• Ca channel blockers
• Nitrates
• Antiplatelet
• ACEI

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Betablockers

• First line
• Class effect therefore choice depends on other
  co-morbidities/compliance/cost
• Reduce the workload of the heart and improve
  oxygen supply to myocardium by prolonging
  diastole
• beta-blockade is indicated by a HR of less than 60

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Calcium Channel blockers

• Induce smooth muscle relaxation
• Studies show good for symptom control
• Rate limiting c-i in heart failure

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Potassium Channel Activators

• Few studies thus far but do show positive results

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Nitrates

• Reduce preload, afterload and oxygen demand via
  venous and arterial dilatateffective in
  prevention and treatment of angina
• No significant difference in efficacy between
  long acting nitrates and betablockers
• More recent studies show amlodipine to be more
  effective than nitrates in controlling exercise
  induced angina in the elderly
• Limit nitrate tolerance by asymmetric dosing and
  sr preparations

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Pharmacology summary

• First line betablockers
• If intolerant use rate limiting CCB, longacting
  nitrates or nicorandil
• GTN for symptomatic relief and pre
  angina-inducing activity

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Combination Therapy

• If not controlled by BB add in CCB (extreme
  caution with rate-limiting)
• Adding ISMN to BB/CCB improved performance on
  clinical endpoints
• If not controlled on 2 drugs ref. cardiology

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Drugs to reduce Cardiovascular events

• If CHD at increased risk of CV events therefore
  eligible for secondary preventative treatments
• All patients should receive antiplatelet and
  statin
• All patients should be considered for an ACEI
  (bit controversial if no LV dysfunction)

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Interventional Cardiology

• Following angiography and assessment of LV
  function patients may be considered for coronary
  revascularisation by PCI (precutaneous
  intervention) or CABG
• Principal indications are symptomatic relief and
  prognostic gain
• (Guideline 57 deals with post-intervention rehab.)

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Psychological and cognitive issues

• Impact of angina on psych. Health and function
  can be measured with specific tools eg Quality of
  life / HADS
• Well documented decreased ratings with angina
  compared to other diseases
• Should be assessed for impact on mood and
  function
• QOF targets include 2 screening questions

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Refactory angina

• Consider Angina Plan (patient help workbook and
  relaxation programme delivered by primary care
  nurse)
• CBT
• Other interventions spinal cord stimulation,
  surgical transmyocardial revascularisation,
  enhanced external counter pulsation

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Follow up

• Patients with angina should receive long-term
  structured follow-up in primary care.