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Management of Stable Angina SIGN 96

Management of Stable Angina SIGN 96. Angina Patient Journey. Patient issues and follow up. Psychological and cognitive issues. Stable angina and non-cardiac surgery. Interventional cardiology and cardiac surgery. Drug intervention to prevent new vascular events.

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Management of Stable Angina SIGN 96

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  1. Management of Stable Angina SIGN 96

  2. Angina Patient Journey Patient issues and follow up Psychological and cognitive issues Stable angina and non-cardiac surgery Interventional cardiology and cardiac surgery Drug intervention to prevent new vascular events Pharmacological management Chest pain evaluation service Diagnosis and Assessment Presentation

  3. Detailed clinical examination Consider need for early referral   12 Lead ECG Measure Hb, TSH, TC, RBS C  B Exercise tolerance test or Myocardial perfusion scintigraphy if unable to exercise or pre existing ECG abnormalities C 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

  4. Confirm diagnosis and assess severity of CHD Use chest pain evaluation service with earliest appointment B C 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

  5. A A A A  Alleviation of angina symptoms Sublingual GTN tablets or spray for immediate relief & before activities known to bring on angina Beta blockers first line therapy Inadequate control of symptoms – add a calcium channel blocker 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

  6. A A A Prevention of new vascular events Long-term statin therapy Long-term standard aspirin 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

  7. A A A Consider for revascularisation One or two vessel disease Left main stem disease Triple vessel disease To improve prognosis Medical therapy failing to control symptoms For symptomatic benefit CABG PCI PCI (CABG if unsuitable)

  8. D Off-pump CABG should not be used as the basis to protect against cognitive decline A B Implement rehabilitation programme after revascularisation D D Revascularisation by CABG Psychological issues Screen for anxiety and depression before, and one year after surgery Advise that cognitive decline is common in first 2 months after surgery For those at higher risk, older, other atherosclerosis and/or existing cognitive impairment take into consideration when evaluating revascularisation options Manage appropriately

  9. Assess patients beliefs about angina when discussing management of risk factors and how to cope with symptoms D D D Consider interventions to alter health beliefs based on psychological principles Consider Angina Plan B B Patients with refractory angina may benefit from an educational and rehabilitative approach based on cognitive behaviour principles prior to considering invasive treatment Consider Angina Plan Psychological issues Impact of angina on quality of life Improving symptom Control Effect of health beliefs Assess impact of angina on mood, quality of life, and function to monitor progress and inform treatment decisions Symptoms uncontrolled and reduced physical functioning despite optimal medical therapy

  10. D B B Patients with CHD undergoing non-cardiac surgery (1) Use risk assessment tool to quantify risk of serious cardiac events Make a pre-op objective assessment of functional capacity before major surgery Further investigate those with co-morbidities undergoing high risk surgery with either an exercise tolerance test or coronary angiography Good teamwork and good communication between surgeon, anaesthetist/physician, cardiologist and patient is required to agree a risk reduction strategy 

  11. D D Patients with CHD undergoing non-cardiac surgery (2) Pre-operative revascularisation Only perform pre-operatively if cardiac symptoms unstable and/or CABG justified on basis of long term outcome If surgery required after PCI Continue dual antiplatelet therapy as far as possible

  12. C D D A Continue through perioperative period B 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 statins before surgery Start low dose aspirin as soon as possible after surgery if withdrawn preoperatively  Continue pre-existing beta blocker in peri-operative period

  13. A Long term follow up Angina symptoms Coronary heart disease confirmed Arrange long term structured follow up in primary care

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