Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris

Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris
DIAGNOSIS
Angina is the commonest symptom of CHD, with a prevalence of 2-4% in the UK adult population It is essentially a set of symptoms resulting from cardiac ischaemia, the most common of which is intense but diffuse, crushing retrosternal pain, normally precipitated by exercise It can also be brought on by eating a large meal, going out in the cold or emotional responses Stable angina refers to a patient whose symptoms are unchanging or only progressing slowly. Patients with rapidly progressive, severe or unstable symptoms should be referred as an emergency to A&E; they are NOT covered by this guideline A working diagnosis of angina is made on the clinical history, especially the nature of the pain. However, there are a number of differential causes of this kind of pain, which may on occasion be difcult to distinguish. The initial assessment process outlined below will aid this discrimination

ASSESSMENT
1. CLINICAL HISTORY
Nature of the pain Precipitants Stability of symptoms Smoking history Exercise grading Occupation Age / sex Dietary assessment Alcohol intake Current medication (including OTC and illicit) Family history Co-morbidities Weight / height and BMI Blood pressure Pulse rate Presence / absence of murmurs (especially aortic stenosis) Signs of hyperlipidaemia Evidence of peripheral vascular disease and/or carotid bruits Signs of thyroid disease Full blood count (to exclude anaemia) Fasting plasma glucose (to exclude diabetes) Fasting lipid prole Thyroid function 12 Lead ECG (an abnormal ECG identies a higher risk population) Biochemistry prole (renal function)

2. EXAMINATION

3. INVESTIGATIONS

Calculation of 10 year CHD risk is NOT possible in angina patients; angina is considered to indicate existing CHD and thus patients in this group are secondary prevention.

Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris
INITIAL MANAGEMENT
Explain the condition to the patient and give initial advice Aim to modify risk factors for CHD as per medication review section Prescribe antiplatelet prophylaxis unless contraindicated as per Medication review section. Prescribe short acting glyceryl trinitrate for acute symptom relief and situational prophylaxis, with appropriate instructions on how to take the treatment Test the effects of beta blocker and titrate to full dose, in case of beta blocker intolerance or poor efcacy attempt montherapy with a calcium channel blocker, long acting nitrate, nicorandil or ivabradine If the effects of beta blocker monotherapy are insufcient, add a dihydropyradine calcium channel blocker In case of beta blocker intolerance substitute with ivabradine If CCB monotherapy or combination therapy is unsuccessful, substitute the long CCB with a long acting nitrate or nicorandil. Consider triple therapy only if optimal two drug regimens are insufcient Consider occupational factors: patients holding LGV and PCV licences should contact the DVLA and stop driving these vehicles. Normal motorists may continue to drive but should inform their insurance company. Patients who operate heavy machinery may also be affected. Review existing medication for exacerbating drugs. If ibuprofen prescribed, select alternative NSAID eg diclofenac (ibuprofen may increase CV risk in these patients) At this point, referral to the Rapid Access Chest Pain Clinic is indicated for: All new patients (for exercise stress testing to conrm diagnosis) Those where diagnosis is in doubt Refer to cardiology for patients unable to undergo exercise stress testing, eg patients: Who are physically incapable of taking the test Who may have aortic stenosis or cardiomyopathy Where the results of the test would not inuence the management of the patient (e.g. if terminally ill)

REFERRAL
The following are those suggested by PRODIGY/SIGN

1. URGENT REFERRAL
Pain on minimal exertion Pain at rest (which may occur at night) Angina which appears to be progressing rapidly despite increasing medical treatment

2. EARLY REFERRAL
People who have had a previous MI, coronary artery bypass graft (CABG) or percutanous transluminal coronary angioplasty (PCTA) and develop angina People who appear to have evidence of a previous MI or other signicant abnormality People who fail to respond to medical treatment People who have an ejection systolic murmur, suggesting aortic stenosis

3. ROUTINE REFERRAL
To conrm or refute a diagnosis with uncertain or atypical symptoms To advise on the management of an individual, particularly where the person has not responded to treatment or risk factor modication The presence of a number of risk factors or a strong family history Patient preference for referral Problems with employment, life insurance, or unacceptable interference with lifestyle Signicant co-morbidity

Treatment should not be delayed whilst awaiting referral. Not all patients may wish to be referred. Referral can also be to Tier 2 cardiology clinic if available. Not all patients with angina need to be referred. The QOF measures the percentage of patients with newly diagnosed angina (diagnosed after April 2003) who are referred for exercise testing and/or specialist assessment, but it is important to note that there are exclusions and for full details of these please refer to section 3.30 of the new General Medical Services Contract. Exclusion include: Some patients may not wish to be referred Some patients may have a more signicant condition e.g. general frailty, advanced years or major co-morbidity, affecting their quality of life and prognosis

Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris
MANAGEMENT OF RISK FACTORS
1. SMOKING
Advise about the risks Advise to stop smoking Refer to or make aware of the smoking cessation service Prescribe pre-quit NRT / bupropion/ veranicline/ nortryptyline as appropriate (see NICE guidance) Increase consumption of oil-rich sh Increase consumption of fruit, vegetables, cereals and foods low in saturated fats (Mediterranean diet) Decrease sugar and salt consumption Encourage to limit alcohol consumption to 3 units per day (men) / 2 units per day (women)

2. DIET / ALCOHOL

3. PHYSICAL ACTIVITY
Encourage to increase level of aerobic exercise to the limits imposed by their condition Aim for 20-30 minutes of exercise 3-5 times per week Refer to exercise on prescription where appropriate

4. WEIGHT / OBESITY
Encourage patient to lose weight to achieve BMI < 25

5. MANAGE CO-MORBIDITIES
Optimal diabetes management (aim for HbA1c < 7%) Monitor blood pressure; where appropriate treat to target Where CHD conrmed, prescribe a statin to reduce to target of total cholesterol/ HDL ratio of 3.5. NB: For many patients who do not reach this target concordance to medications is often the reason All these interventions should be recorded using appropriate codes

CLASSIFICATION OF ANGINA SEVERITY ACCORDING TO THE CANADIAN CARDIOVASCULAR SOCIETY

CLASS LEVEL OF SYMPTOMS Class I: Ordinary activity does not cause angina Class II: Slight limitation of ordinary activity
Angina with strenuous or rapid or prolonged exertion only

Angina on walking or climbing stairs rapidly, walking uphill or exertion after meals, in cold weather, when under emotional stress, or only during the rst few hours after awakening

Class III: Marked limitation of ordinary physical activity

Angina on walking one or two blocks on the level or one ight of stairs at a normal pace under normal conditions Equivalent to 100200 m.

Class IV: Inability to carry out any physical activity without discomfort or angina at rest

Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris
REFERRAL PATHWAY
Patients presents with existing but worsening angina Patient presents with recent onset of symptoms

GP assessment. History inc PMH and Meds and exam - risk factors - Investigations o FBC o Biochemical Profile o Fasting Lipid Profile & blood glucose o Pulse & BP o 12 lead ECG

Pain on minimal exertion -Unstable angina

Admit

Referral to Tier 2

Referral to cardiologist

Electronic referral to Rapid Access Chest Pain Clinic (Consider nGMS exclusion criteria)

Cardiology Opinion refer to Rapid Access Chest Pain Pathway

In-patients suspected of having angina

Functional Assessment

Angiography

ANGINA
Cardiac Rehabilitation & Optimise Medical management (European Society of Cardiology Algorithm for Stable Angina)

Continue Medical management

PTCA

CABG

Further Cardiology Review

Referral back to GP

At-least annual GP Review Put patient on GP register Give patient heart health record Medication Review Risk factor assessment and active management Symptom assessment and active management

Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris

Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris
GENERAL PRACTICE REVIEW AFTER REFERRAL BACK TO GP:
RICK FACTOR ASSESSMENT AND ACTIVE MANAGEMENT:
1. SMOKING
Advise about the risks Advise to stop smoking Refer to or make aware of the smoking cessation service Prescribe NRT / bupropion as appropriate (see NICE guidance) Increase consumption of oil-rich sh Increase consumption of fruit, vegetables, cereals and foods low in saturated fats (Mediterranean diet) Decrease sugar and salt consumption Encourage to limit alcohol consumption to 3 units per day (men) / 2 units per day (women)

2. DIET / ALCOHOL

3. PHYSICAL ACTIVITY
Encourage to increase level of aerobic exercise to the limits imposed by their condition Aim for 20-30 minutes of exercise 3-5 times per week Refer to exercise on prescription where appropriate

4. WEIGHT / OBESITY
Encourage patient to lose weight to achieve BMI < 25

5. MANAGE CO-MORBIDITIES
Manage diabetes (aim for HbA1c < 7%) aim for optimal diabetes management Monitor blood pressure; where appropriate treat to target Where CHD conrmed, prescribe a statin to reduce to target All these interventions should be recorded using appropriate codes

MEDICATION REVIEW:
RECOMMENDATIONS FOR PHARMACOLOGICAL THERAPY TO IMPROVE PROGNOSIS IN PATIENTS WITH STABLE ANGINA
Aspirin 75 mg daily in all patients without specic contraindications (ie active GI bleeding, aspirin allergy or previous aspirin intolerance). Consider Clopidogrel as an alternative antiplatelet agent in patients with stable angina who cannot take aspirin eg Aspirin allergic. Statin therapy for all patients with coronary disease. ACE-inhibitor therapy in patients with coincident indications for ACE-inhibition, such as hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes Oral beta blocker therapy in patients post-MI or with heart failure ACE-inhibitor therapy in all patients with angina and proven coronary disease.

RECOMMENDATIONS FOR PHARMACOLOGICAL THERAPY TO IMPROVE SYMPTOMS AND/OR REDUCE ISCHAEMIA IN PATIENTS WITH STABLE ANGINA.
PROVIDE Short-acting nitroglycerin for acute symptom relief and situational prophylaxis, with appropriate instructions on how to use the treatment Test the effects of a beta-1 blocker, and titrate to full dose; consider the need for 24 h protection against ischaemia In case of beta-blocker intolerance or poor efcacy attempt monotherapy with a calcium channel blocker, long acting nitrate, nicorandil or ivabradine If the effects of beta-blocker monotherapy are insufcient, add a dihydropyridine calcium channel blocker In case of beta-blocker intolerance substitute ivabradine If CCB monotherapy or combination therapy (CCB with beta-blocker) is unsuccessful, substitute the CCB with a long-acting nitrate or nicorandil. Be careful to avoid nitrate tolerance Metabolic agents may be used where available as add on therapy, or as substitution therapy when conventional drugs are not tolerated Consider triple therapy only if optimal two drug regimens are insufcient, and evaluate the effects of additional drugs carefully. Patients whose symptoms are poorly controlled on double therapy should be assessed for suitability for revascularization, as should those who express a strong preference for revascularization rather than pharmacological therapy. The ongoing need for medication to improve prognosis irrespective of revascularization status, and the balance of risk and benet on an individual basis, should be explained in detail. If inadequate symptom control after 3 months consider PCI or CABG and refer back to cardiology.

Anti-anginal drug treatment should be tailored to the needs of the individual patient, and should be monitored individually.

Primary Care Guidelines for the Treatment of Chronic Stable Angina Pectoris
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Anon. Management of stable angina. SIGN Guideline Number 51 Department of Health. Stable Angina (Chapter 4) National Service Framework for Coronary Heart Disease. London: DoH, 2000 Anon. How common are side effects associated with betablocker therapy? MeReC Extra, Number 7, November 2002 de Bono D, et al. Investigation and management of stable angina: revised guidelines 1998. Heart, May 1999; 81: 546-555 Anon. Stable angina. PRODIGY Guidelines Anon. Secondary prevention of ischaemic events. Clinical Evidence,Volume 7, BMJ 2002 North of England Stable Angina Guideline Development Group. North of England evidence based guidelines development project: summary version of evidence based guideline for the primary care management of stable angina. Br Med J, 1996; 312: 827-32 Consumers Association. Too many beta-blockers. Drug Ther Bull, 1996; 34: 49-52 Consumers Association. Calcium antagonists for cardiovascular disease. Drug Ther Bull, 1993; 31: 81-4 Medicines Resource Centre. Nicorandil, a novel antianginal drug. MeReC Bulletin ,1995; 6: 24 Consumers Association. Nicorandil for angina. Drug Ther Bull, 1995; 33: 89-92 Anon. Nicorandil in stable angina. MeReC Extra, Number 5, June 2002 Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. European Heart Journal (2006) 27, 13411381 R J P Lewin, G Furze, J Robinson, K Grifth, S Wiseman, M Pye and R Boyle. A randomised controlled trial of a self-management plan for patients with newly diagnosed angina. British Journal of General Practice, March 2002

DEVELOPED FOR THE GREATER MANCHESTER AND CHESHIRE CARDIAC NETWORK BY THE PRACTITIONERS WITH SPECIALIST INTEREST IN CARDIOLOGY LEADING LIGHTS GROUP.
The Practitioners with Specialist Interest in Cardiology Leading Lights Group: Dr Ivan Benett Manchester P.C.T. Mrs Paula Bithell Rochdale Inrmary Mr Richard Carty Faireld General Hospital Dr Eddie Thornton Chan Tameside and Glossop P.C.T. Dr Sumit Guhathakurta Bolton P.C.T. Mr Andrew Jackson Greater Manchester and Cheshire Cardiac network Dr Jith Joseph Central and Eastern Cheshire P.C.T. Dr Ian Milnes Oldham P.C.T. Dr Washik Parkar Manchester P.C.T. Dr Masud Prodhan Trafford P.C.T. Mrs Andrea Saycell Royal Oldham Hopsital Dr Kenneth Shearer Manchester P.C.T. Dr Linda Stalley Salford P.C.T Dr Mark White Stockport P.C.T. Dr Adu Yusuf Tameside and Glossop P.C.T.