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. Patient presents with chest pain likely to be due to stable angina
Consider characteristics of pain and associated features
Detailed clinical
examination 
Consider need for early referral 
12 Lead ECG Measure Hb, TSH, TC, RBS  C
Refer for confirmation of diagnosis to chest pain service B
Exercise tolerance test or Myocardial perfusion scintigraphy if unable to exercise or pre existing ECG abnormalities C
Coronary
angiography  B

4. Care of patients with suspected angina
Confirm diagnosis and assess severity of CHD
Use chest pain evaluation service with
earliest appointment B
Early access to angiography and coronary artery bypass surgery may reduce the risk of adverse cardiac events and impaired quality of life C

5. Alleviation of angina symptoms
Sublingual GTN tablets or spray for immediate relief
& before activities known to bring on angina A
Beta blockers first line therapy A
Inadequate control of symptoms – add a calcium channel blocker A
If intolerant of beta blockers treat with a rate limiting calcium channel blocker, long acting nitrates or nicorandil A
Consider referral to a cardiologist if symptoms not controlled on maximum therapeutic doses of two drugs 

6. Prevention of new vascular events
Long-term standard aspirin therapy
Long-term
statin therapy A A
Consider ACEI in all patients with stable angina A
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. Consider for revascularisation
One or two vessel
disease
Left main stem
disease
Triple
vessel
disease
Medical therapy failing to control symptoms
To improve prognosis
For symptomatic benefit
CABG
PCI A A
PCI
(CABG if unsuitable) A

8. Revascularisation by CABG
Psychological issues D
Screen for anxiety and depression before, and one year after surgery
Advise that cognitive decline is common in first 2 months after surgery
Off-pump CABG should not be used as the basis to protect against cognitive decline A B
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 D D
Manage appropriately

9. Psychological issues Impact of angina on quality of life
Improving symptom Control
Effect of health beliefs
Assess patients beliefs about angina when discussing management of risk factors and how to cope with symptoms D
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 D
Consider interventions
to alter health beliefs based on
psychological principles
Consider Angina Plan B
Consider Angina Plan B
Patients with refractory angina may benefit from an educational and rehabilitative approach based on cognitive behaviour principles prior to considering invasive treatment D

10. 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 B D
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 B 

11. 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 D
Continue dual
antiplatelet therapy
as far as possible D

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 A
Only withhold low dose aspirin if high related bleeding risk
Start statins
before surgery D C
Start low dose
aspirin as soon
as possible after surgery if withdrawn preoperatively
Continue
through
perioperative
period D 
Continue pre-existing beta blocker in peri-operative period B

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