1. Stable Angina management according to NICE guidelines
Primary Care Cardiac Service

2. Definition of Angina British Heart Foundation (https://www.bhf.org.uk)
A pain or discomfort most commonly felt in chest, which may also be felt in the arms, neck, stomach or jaw.
Angina occurs when coronary arteries become narrowed and not enough oxygen rich blood can reach the heart muscle, particular when its demands are high, such as during exercise.

3. Types of Angina
stable angina – Chronic medical condition where angina attacks are brought on by an obvious trigger (such as exercise) and improve with medication and rest.
unstable angina – where angina attacks are more unpredictable, occurring with no obvious trigger and continuing despite resting.

4. Provide training & education Conduct audit
Angina is the main symptom of myocardial ischemia and is usually caused by atherosclerotic plaque, obstructing the coronary artery, restricting blood flow, and therefore oxygen delivery to heart muscle.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

5. Angina classification Canadian cardiovascular society angina classification
Class 1 Ordinary activity such as walking or climbing stairs does not precipitate angina
Class 11 Angina precipitated by emotion, cold weather or meals and by walking upstairs
Class111 Marked limitation of ordinary physical activity
Class 1V Inability to carry out any physical activity without discomfort-angina symptoms, may present at rest
(Campeau L. Grading of angina pectoris. Circulation 1976;1976;54(3): in sign guidelines)

6. Statistics Team Statistics
Number of cases: 71,330 men and 48,405 women in 2014.
The population of the UK is 64.1 million.
Health survey for England in 2006 reported that 8% of men and 3% of women aged years had angina. Figures for ages were 14% men and 8% women.
British Heart Foundation (
Guidance.nice.org.uk/cg126
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

7. Effects
A diagnosis of Angina can have a significant impact on patients level of functioning - in one survey angina scored their general health as twice as poor as those who had had a stroke. ( lyons,RA Lo SV, Littlepage BN Comparative health status with 11 common illnesses in Wales J Epideminol Community health 1994;48(4): in sign guideline)
A Tayside study showed that patients with angina had high levels of anxiety and depression. (Smith K, Ross D, Connolly E investigating six month health outcomes of patients with angina discharged from chest pain service, European Journal cardiovascular nursing 2002;1(4): in sign guideline)

8. Living with Angina
In another survey patients had a low level of factual knowledge about their illness and poor medication adherence. (Mac Dermott AF Living with angina pectoris-a phenomenological study. European Journal of cardiovascular nursing 2002:1(4): in sign guideline)

9. Guidelines available Control Team
Nice chest pain of recent onset march 2010 clinical guideline 95 guidance.nice.org.uk/cg95
Management of stable angina December guidance.nice.org.uk/cg126
Nice MI secondary prevention guidance.nice.org.uk/cg172
Management of stable angina 96 at
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

10. Symptoms that may lead to non angina diagnosis
Continuous or prolonged pain
Unrelated to activity
Brought on by breathing
Associated symptoms - dizziness, palpitations, tingling, difficulty swallowing
Consider musculoskeletal or gastrointestinal

11. Assessing and diagnosing suspected stable angina (Nice guidelines)
& Control Team
Assessing and diagnosing suspected stable angina (Nice guidelines)
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12. Angina pathway GP diagnosis. Then to either:- Accident and Emergency
Rapid access chest pain clinic Nottingham City Hospital for further investigations
If likelihood greater than 90% diagnostic investigation not required - manage as angina

13. Diagnosis
Team
Clinical assessment alone.
Clinical assessment plus diagnosis testing.
Use table of people estimated to have coronary artery disease according to typicality of symptoms, age, sex and risk factors.
Remember a significant number of patients with chest pain may not have angina and assessment should try and identify alternative diagnosis at an early stage
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

14. & Control Team Assessing chest pain
Location.
Radiation.
Severity.
Duration.
Frequency.
Factors that provoke or relieve.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
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Conduct audit

15. Risk factors Smoking Hypertension Diabetes
Family history Male <55, Female <65 first degree relative
Raised cholesterol
Overweight
Poor diet
Raised waist measurement
Lack of exercise

16. More factors to consider
Anaemia
Glucose levels
Thyroid function tests
Depression and social isolation

17. & Control Team Making a diagnosis
Angina pain is constricting discomfort in chest, neck, shoulders, jaw or arms.
Precipitated by physical exertion.
Relieved with GTN or rest
3 factors = typical angina
2 Factors= atypical angina
1 factor non angina chest pain
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

18. The Role of the Infection Prevention & Control Team
Adapted from Pryor DB, Shaw L, McCants CB et al. (1993) Value of the history and physical in identifying patients at increased risk for coronary artery disease. Annals of Internal Medicine 118(2): 81–90. taken from Nice guidelines 95
The Role of the Infection Prevention & Control Team
Non-angina chest pain Atypical angina Typical angina
Men Women Men Women Men Women
Age (years) Lo Hi Lo Hi Lo Hi Lo Hi Lo Hi Lo Hi
For men older than 70 with atypical or typical symptoms, assume an estimate > 90%.
For women older than 70, assume an estimate of 61–90% EXCEPT women at high risk
AND with typical symptoms where a risk of > 90% should be assumed.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
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19. & Control Team Table shows
Values are per cent of people at each mid-decade age with significant coronary artery disease (CAD.
Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre).
Lo = Low risk = none of these three.
The 'non-angina chest pain' columns represent people with symptoms of non-angina chest
pain, who would not be investigated for stable angina routinely.
Note:
These results are likely to overestimate CAD in primary care populations.
If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table
Taken from Nice guidelines 95.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
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Conduct audit

20. Simplified, what Nice says about chest pain diagnosis
& Control Team
If patient presents with chest pain or had chest pain in last 12 hours with abnormal ecg or unavailable ecg he should be seen as emergency admission.
If ACS suspected but no pain in last 12 hours and ECG normal refer for urgent same day assessment.
If chest pain more than 72 hours, clinical assessment, ECG , Tropi levels, clinical assess how urgent they should be seen.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

21. In Rapid access chest pain clinic
& Control Team
Review risk with table
If risk >90% assume angina.
If estimate risk of CAD 61-90% invasive coronary angiography will be first line diagnostic investigation if appropriate
If risk of CAD 30-60% Non invasive functional imaging will be offered
If risk of CAD10-29% CT scoring will be done CT calcium scoring
0 =normal >400 offer invasive angiography
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

22. Investigations CT scan Functional imaging Stress Echo MRI scan
Invasive angiography

23. & Control Team Management Aims
To stop or minimise symptoms.
Improve quality of life and long term morbidity and mortality.
Management options include lifestyle advice, drug treatment and revascularisation using percutaneous or surgical techniques.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

24. Team When angina diagnosed
Management includes
lifestyle advice
drug treatment or revascularisation using percutaneous or surgical techniques or combination
Give the patient the information to safely manage their condition
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

25. Analysis of comparative efficacy of treatments for people with stable angina
Analysis is difficult because of recent advances in medication and revascularisation strategies over several decades
Trials of drug treatments versus coronary artery bypass surgery in patients were carried out more than 25 years ago and showed a survival advantage with surgery in patients with severe coronary artery bypass surgery, but this was pre statins and other secondary prevention treatments and these treatments have had a significant effect on morbidity and mortality.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

26. Nice advises key priorities are to:
& Control Team
Explore and address issues according to personal needs.
Self Management skills such as pacing their activities and goal setting, explore impact of stress, advice about physical exertion
Offer optimal drug treatment consisting of 1-2 antianginal drugs as necessary plus drugs for secondary prevention
Revascularisation (CABG) or percutaneous coronary intervention (PCI) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medication
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

27. Primary Care Cardiac Service as part of the chest pain pathway Cardiac rehabilitation
Following Revascularisation
Stable heart failure
STABLE ANGINA
Post valve surgery, heart transplant, LVAD’s
TIA

28. Who Newly diagnosed patients can be referred once diagnosis confirmed
Any patients with existing stable angina can also be referred if they have had a recent change in their symptoms

29. Why
There is overwhelming evidence that comprehensive Cardiac Rehabilitation reduces mortality.
There is emerging evidence that it is also associated with a reduction in morbidity and a reduction in unplanned readmissions.
It improves functional capacity and perceived quality of life and supports early return to work.
It aids the development of self management skills
Secondary prevention forms an integral part of the service

30. The 7 core components of Cardiac Rehabilitation
Health behaviour change and education
Lifestyle and risk factor management
Psychosocial support
Medical risk factor management
Cardio protective therapies
Long term management
Audit and evaluation

31. We offer information and support for people with stable angina
& Control Team
Explain stable angina and include factors that can provoke angina such as exertion, emotional stress, exposure to cold, eating a heavy meal. Discuss long term management.
Advise to seek help if there is a sudden worsening of condition.
Discuss risks and benefits of treatment.
Assess lifestyle and offer interventions.
Explore individual needs.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

32. Cardiac Rehabilitation - pathway
Patients are assessed within 10 working days of referral
They will have a case manager who will work with the patient for a minimum of 3 months.
Patients are assessed at home and can access a range of options to meet their needs
Home based 1-1 support
Group classes – Clifton, Bakersfield, Bells Lane
Referred into many other sources of support

33. Expected outcomes
Maximise uptake of cardiac rehab by providing a personalised programme delivered at a choice of venues.
Improve physical health and quality of life.
Promote and equip patients to self-manage by encouraging goal setting and building on service users’ knowledge base about their condition.
Reduce hospital admissions
Reduce inequalities and improve access for hard to reach groups
Improve the experience and choice of patients by staff having a close working relationship with local GP’s and a depth of specialist knowledge.

34. How to refer? Via Nottingham City Health and Care Point
and select option 5
Online via
Referrals cannot be made directly to the service although we are happy to speak to you about the suitability of any referral you wish to make

35. Primary care cardiac team: Who are we?
A multi-disciplinary team comprising of:
Community Heart/TIA Nurses
Cardiac Physiotherapists
Occupational Therapist
Assistant Practitioner
Heart Failure Specialist Nurses
Administrator
Volunteer Counsellors
Support from secondary care cardiology

36. How to contact us The service is based at Tel: 0115 88 34733
New Brook House
Room 29
385 Alfreton Road
Radford
Nottingham
NG7 5LR
Tel:

37. Drugs

38. Drugs for treating Angina as Nice guidelines
& Control Team
Beta-blocker or calcium channel blocker first line treatment, with decision based on co morbidities, contraindications and persons preference
If cannot tolerate either of these offer other option
If symptoms not controlled on either consider switching or offering both
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
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Conduct audit

39. Drugs for treating Angina
& Control Team
Nice says If neither beta-blocker or calcium channel blocker not tolerated consider monotherapy of either
Long acting nitrate
Ivabradine
Nicorandil
Ranolazine
Decision based on co morbidities, contraindications and persons preference and cost
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

40. & Control Team Nice recommends
GTN spray
Consider Aspirin 75mg taking into account risk of bleeding
Consider ACE
Offer Statin treatment
Offer treatment for hypertension
Offer optimal treatment 1-2 antianginal drugs
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

41. Discuss
& Control Team
The aim of drugs how they work to offer secondary prevention and prevent episodes of angina
Discuss side effects
Arrange review 2-4 weeks later and titrate according to symptoms to maximum tolerable dose
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

42. Nice says consider adding third anti angina only if….
Team
Symptoms are not satisfactorily controlled.
Person awaiting revascularisation or revascularisation is not considered appropriate or acceptable
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

43. Nice advises people with symptoms not satisfactorily controlled with optimal medication.
& Control Team
Will be considered for CABG or PCI.
Angiography will be offered to guide strategy for treatment.
Provide advice & information about infections & infection prevention & control issues
Write & update infection prevention & control policies that are available on the POD
Provide training & education
Conduct audit

44. References
Nice chest pain of recent onset march 2010 clinical guideline 95 guidance.nice.org.uk/cg95
Management of stable angina December guidance.nice.org.uk/cg126
Nice MI secondary prevention guidance.nice.org.uk/cg172
Management of stable angina 96 at
British Heart Foundation (
British National Formulary bnf.org
BACPR Cardiovascular diseases prevention and rehab 2012
Sign guidelines

45. Thank you for listening