Stable angina

1. Stable angina Implementing NICE guidance July 2011 NICE clinical guideline 126

2. What this presentation covers • Background • Epidemiology • Scope • Key priorities for implementation Further recommendation areas • Costs and savings Discussion • Find out more

3. 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.

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. Anti-anginal drug treatment – drugs for treating stable angina • Offer either a beta blocker or calcium channel blocker as first-line treatment for stable angina • Consider switching to the other option Beta blocker or calcium channel blocker not tolerated • Consider either switching to the other option or using a combination of the two 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 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.

10. Investigation and revascularisation (1) When symptoms are notsatisfactorily 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.

11. Investigation and revascularisation (2) When symptoms are notsatisfactorily 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.

12. Investigation and revascularisation (3) When symptoms are notsatisfactorily 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

13. Investigation and revascularisation (4) When symptoms are notsatisfactorily 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.

14. Investigation and revascularisation (5) When symptoms are notsatisfactorily 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.

15. 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.

16. 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

17. ‘Do not’ recommendations Do not : • exclude people from treatment based on their age • investigate or treat symptoms differently in men and women or in different ethnic groups • offer vitamin or fish oil supplements • offer TENS, EECP or acupuncture • routinely offer drugs for secondary prevention of cardiovascular disease to people with suspected cardiac syndrome X.

18. 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

19. 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?

20. 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

21. 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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