Managing Stable Angina

Managing Stable Angina

What is Stable Angina?

Stable angina pectoris is caused by limited blood flow and supply of oxygen to the heart muscle¹, which causes myocardial ischemia and is associated with around 3%-4% of myocardial infarctions (MI) or deaths.² Patients diagnosed with this condition may experience pain around the upper parts of their body and may find it difficult to participate in exercise or strenuous activity.¹

How can stable angina be managed?

The overall objectives for treating patients suffering from stable angina pectoris include:³

• improving prognosis by lowering the risk of future myocardial infarction or death
• enhancing their quality of life by reducing their symptoms
• providing them with treatments they can tolerate well with minimal side effects

Based on the latest guidelines from the National Institute for Health and Care Excellence (NICE)⁴ and the European Society of Cardiology (ESC)⁵, when managing patients with stable angina pectoris, the care and treatment of each patient should be tailored to their needs and preferences. The following therapies should be considered:³

Short-acting sublingual glyceryl trinitrate (GTN)

The ESC⁵ and NICE⁴ recommend prescribing GTN to treat ongoing anginal episodes. GTN can effectively relieve symptoms and prevent exertional anginal attacks for patients diagnosed with stable angina.³ All patients should be consulted about the potential benefits of using nitrates before exercise or activity and should be advised on the best route of administration i.e. tablets, spray, sublingual or buccal methods.³

First-line antianginal therapy

For first-line therapy NICE⁴ and ESC⁵ recommend either beta blockers or calcium antagonists to prevent anginal episodes. Choosing which treatment to give to a patient should depend on an individual’s co-morbidities, contraindications and their preferences. If patients cannot tolerate one of the therapies, it should be switched to the other option. All anti-anginal therapies should be titrated, depending on the patients symptoms.⁴

Second-line antianginal therapy³

A second-line therapy should be considered in patients:

• where symptoms persist despite optimising the dose of beta blockers or calcium channel blockers
• who are intolerant to first-line therapy
• where blood pressure and heart rate limit the use of first-line therapy

Available second line therapies include: ranolazine, long-acting nitrates, ivabradine and nicrorandil.

Which second-line treatment is given to a patient should depend on their co-morbidities, contraindications, the patient’s preference and drug costs.⁴

Adapted from Wee Y et al, 2015

There are many different factors to consider when optimising medical therapy for the management of stable angina.⁶

Prevention of cardiovascular events

Patients with coronary artery disease could consider taking a low dose of aspirin of 75mg/day.⁴ Evidence suggests that stable angina patients should use aspirin long term as discontinuing treatment could increase the risk of occlusive vascular events.⁷

Risk factor management³

Aside from the determinant risks of age and sex, there are other risk factors that must be managed effectively to reduce the risk of cardiovascular events. These risks can include, amongst others; a raised blood pressure, diabetic management, smoking and high cholesterol.

Lifestyle management³

Patients’ lifestyle choices should also be monitored, and they should receive advice and support on how to manage their lifestyle effectively, as this could contribute towards cardiovascular events.

Physical activity³

Patients should be encouraged to exercise within their limits as it will increase exercise tolerance and reduce their symptoms, prompting favourable changes in weight, blood pressure, blood lipids, glucose tolerance and insulin sensitivity.

Psychosocial stress³

Psychosocial factors such as stress and anxiety may provoke angina. It is important that patients are reassured by their healthcare professionals and offered advice on the benefits of relaxation techniques and other methods of stress control.

Diet³

Patients should be advised to follow an appropriate diet limiting:

• total fat intake to 30% or less of total energy intake
• saturated fats to 10% or less of total energy intake
• dietary cholesterol to less than 300mg/day
• saturated fats, replacing them with monosaturated and polysaturated fats.

Patients should be encouraged to eat at least:

• five portions of fruit and veg per day
• two portions of fish per week, including a portion of oily fish.

Stop Smoking³

Smokers should be advised to stop smoking and be supported by:

• being offered support and advice
• being offered referrals to an intensive support services (e.g. NHS stop smoking services)

Following this guidance will help identify the optimal therapy to improve the health and quality of life of patients with stable angina pectoris.³ To further enhance your understanding of how to manage angina patients, please complete the BJC learning modules on angina

The evolving treatment management landscape: A case study⁸

Stable angina falls within the clinical category of chronic coronary syndrome (CCS). Patients who visit the emergency department with chest pain are commonly diagnosed with CCS. If left unmanaged, CCS may not only negatively impact patients outcomes, but can also cost the NHS large sums of money due to lengthy hospital stays.

So how can we ensure CCS is optimally managed in the hospital setting? To achieve this, the AMU and cardiology department at West Middlesex University Hospital introduced a new care pathway which involved a three-prong approach:

1. To simplify decision making for non-cardiologists, they developed new guidelines for the management of CCS chest pain in the AMU, which were centred around a series of step by step algorithms. The core algorithm gives recommendations for patients with stable angina who are not already on antianginal therapy , whilst further algorithms give prescribing advice for patients who; are already on anti-anginal therapy, have diabetes, suffer from heart failure or renal impairment and older people.
2. They set up a consultant-led rapid access HOT clinic to enable the safe and efficient discharge of CCS patients who are at a low risk of major adverse cardiac events based on the HEART score.
3. They gave patients autonomy over their care by creating a Care Information Exchange app, a personal health record that could be shared with HCPs.

The team at West Middlesex has already seen an improvement in patient symptom management since the implementation of this new pathway, resulting in a significant reduction in length of hospital stay and burden on cardiologists. This has also led to large financial savings.

Other trusts around England are now incorporating aspects of the pathway into their hospitals. To find out more about the pathway and how you could implement it in your hospital, read this best practice guidance document document from Consultant Cardiologist Dr. Emmanuel Ako and Consultant in Acute General Internal Medicine, Dr. Luke Smith who were the drivers of change at West Middlesex.

References

1. NHS Angina Overview, April 2021. https://www.nhs.uk/conditions/angina/ (Accessed on 15^th July 2021)
2. Joshi PH & de Lemos JA, JAMA 2021; 325 (17): 1765-1778
3. The British Journal of Cardiology (BJC), Angina Module 6: secondary prevention and treatment. 2020. https://bjcardio.co.uk/category/angina-learning/ (Accessed on 15^th July 2021)
4. Stable angina: management (CG126), NICE clinical guideline. Published 23 July 2011, last updated August 2016: 1-22
5. Knuuti J et al, 2019. ESC Guidelines for the diagnosis and management of chronic coronary syndromes, European Heart Journal 2020. 41(3): 407-477
6. Wee, Y. et al, Aust.Presc.2015;38(4): 131-136
7. Rodríguez, L. et al, BMJ. 2011; 343:d4094
8. Ako E. & Smith L. Improving outcomes in the management of patients with chronic coronary syndrome and stable anginal chest pain for the acute and general physician. MGP. 2021.