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SIGN 96: Management of stable angina


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SIGN 96: Management of stable angina

  1. 1. Management of Stable Angina SIGN 96
  2. 2. Angina 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
  3. 3. Patient presents with chest pain likely to be due to stable angina Consider characteristics of pain and associated features Refer for confirmation of diagnosis to chest pain service Coronary angiography  B Detailed clinical examination  Consider need for early referral  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
  4. 4. Care of patients with suspected angina Early access to angiography and coronary artery bypass surgery may reduce the risk of adverse cardiac events and impaired quality of life Confirm diagnosis and assess severity of CHD Use chest pain evaluation service with earliest appointment B C
  5. 5. 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 If intolerant of beta blockers treat with a rate limiting calcium channel blocker, long acting nitrates or nicorandil Consider referral to a cardiologist if symptoms not controlled on maximum therapeutic doses of two drugs A A A A 
  6. 6. Prevention of new vascular events 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 Long-term standard aspirin therapy Long-term statin therapy A A A
  7. 7. Consider for revascularisation For symptomatic benefit PCI (CABG if unsuitable) Left main stem disease Triple vessel disease CABG To improve prognosis PCI Medical therapy failing to control symptoms One or two vessel disease A A A
  8. 8. 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 decline B D D D A
  9. 9. Psychological issues 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 Effect of health beliefs Consider Angina Plan 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 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
  10. 10. 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 an exercise 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
  11. 11. Patients with CHD undergoing non-cardiac surgery (2) 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 Continue dual antiplatelet therapy as far as possible D D
  12. 12. Patients with CHD undergoing non-cardiac surgery (3) 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 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 period B D A C D
  13. 13. Long term follow up Angina symptoms Coronary heart disease confirmed Arrange long term structured follow up in primary care A