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Management of Stable Angina SIGN 96 Angina Patient Journey Patient issues and follow up Interventional cardiology and cardiac surgery Psychological and cognitive issues Stable angina and non-cardiac surgery Drug intervention to prevent new vascular events Pharmacological management Chest pain evaluation service Diagnosis and Assessment Presentation 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 C 12 Lead ECG Measure Hb, TSH, TC, RBS B Refer for confirmation of diagnosis to chest pain service C Coronary angiography Exercise tolerance test or Myocardial perfusion scintigraphy if unable to exercise or pre existing B ECG abnormalities Care of patients with suspected angina Confirm diagnosis and assess severity of CHD B Use chest pain evaluation service with earliest appointment Early access to angiography and coronary artery bypass surgery may reduce the risk of adverse cardiac events and impaired quality of life C Alleviation of angina symptoms A A Beta blockers first line therapy Sublingual GTN tablets or spray for immediate relief & before activities known to bring on angina Inadequate control of symptoms – add a A calcium channel blocker If intolerant of beta blockers treat with a rate limiting A calcium channel blocker, long acting nitrates or nicorandil Consider referral to a cardiologist if symptoms not controlled on maximum therapeutic doses of two drugs Prevention of new vascular events A Long-term standard aspirin therapy A A Long-term statin 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 Consider for revascularisation One or two vessel disease Left main stem disease To improve prognosis Medical therapy failing to control symptoms For symptomatic benefit A PCI (CABG if unsuitable) Triple vessel disease A CABG A PCI Revascularisation by CABG Psychological issues Advise that cognitive decline is common in first 2 months after surgery B D For those at higher risk, older, other atherosclerosis and/or existing cognitive impairment take into consideration when evaluating revascularisation options D Screen for anxiety and depression before, and one year after surgery D Manage appropriately Implement rehabilitation programme after revascularisation A Off-pump CABG should not be used as the basis to protect against cognitive decline Psychological issues Impact of angina on quality of life Improving symptom Control Effect of health beliefs D Assess impact of angina on mood, quality of life, and function to monitor progress and inform treatment decisions D Symptoms uncontrolled and reduced physical functioning despite optimal medical therapy B Consider Angina Plan D Assess patients beliefs about angina when discussing management of risk factors and how to cope with symptoms Consider interventions to alter health beliefs based on B psychological principles Consider Angina Plan Patients with refractory angina may benefit from an educational and rehabilitative approach based on cognitive behaviour principles prior to considering invasive treatment Patients with CHD undergoing non-cardiac surgery (1) Use risk assessment tool to quantify risk of serious cardiac events B Further investigate those with B co-morbidities undergoing high risk surgery with either an exercise tolerance test or coronary angiography Make a pre-op objective assessment of functional capacity before major surgery D Good teamwork and good communication between surgeon, anaesthetist/physician, cardiologist and patient is required to agree a risk reduction strategy Patients with CHD undergoing non-cardiac surgery (2) Pre-operative revascularisation Only perform pre-operatively if cardiac symptoms unstable D and/or CABG justified on basis of long term outcome If surgery required after PCI D Continue dual antiplatelet therapy as far as possible Patients with CHD undergoing non-cardiac surgery (3) A 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 C bleeding risk D Continue pre-existing B beta blocker in perioperative period Start low dose aspirin as soon as possible after surgery if withdrawn preoperatively D Start statins before surgery Continue through perioperative period Long term follow up Angina symptoms Coronary heart disease confirmed A Arrange long term structured follow up in primary care