Management of angina

Current situation  

Angina is a very common problem. In the UK more than two million people are affected by the condition.   

Thirty per cent of patients with recent-onset angina will suffer a major cardiac event such as death, MI or revascularisation within two years.  

What is the evidence?  

Most of the existing evidence would suggest that a beta-blocker is the first-line prophylactic agent when regular symptom control of angina is required (unless contraindicated).   

Management options for patients with refractory angina include procedures which are still being evaluated in trials, for example spinal cord stimulation and transmural myocardial laser revascularisation (Curr Cardiol Rep 2006; 8: 272). 

Ivabradine is the first selective sinus node If inhibitor. It reduces heart rate while maintaining myocardial contractility and atrioventricular conduction. It has been shown to be as effective as atenolol in patients with stable angina (Eur Heart J 2005; 26: 2,529).  

Women with angina often present differently to men. Cardiac investigations such as ECG and exercise tolerance tests are actually less specific and less sensitive in women (BMJ 2005; 331: 467).  

Analysis of the IONA trial has shown that adding nicorandil to existing antianginal treatment is cost-effective for patients because it leads to lower incidence of cardiovascular disease (CVD) (Heart 2006; 92: 619).  

Implications for practice  

There are still wide variations in the quality of care.  There is some evidence that gaps remain between best practice and usual care in the management of stable angina (Eur Heart J 2005; 26: 996).   

One study showed that only 40 per cent of those people taking lipid-lowering treatment actually had cholesterol levels below target. Only about half of those at high risk of CVD were treated with a statin (Circulation 2006; 113: 647).  

Most GPs now have access to chest pain clinics.   

Available guidelines  

The SIGN guidelines recommend that all patients with recent-onset angina should be considered for review by a cardiologist.   

The NSF for CHD states that people with angina should be offered investigation and treatment to relieve their pain and also to reduce the risk of coronary events (NSF for CHD. DoH. London: 2000).  

Although current guidelines do not include ACE inhibitors, many clinicians prescribe ACE inhibitors for patients with angina.  

Useful websites — British Cardiac Society — Primary Care Cardiovascular Society — British Hypertension Society  

Dr Louise Newson is a GP in the West Midlands and author of ‘Hot Topics for MRCGP and General Practitioners’, Pas Test 2006  

Key points  

CHD is the most common cause of death in the UK.

ACE inhibitors are increasingly being used.  

Many patients are still not reaching target cholesterol levels.  

New treatments for angina are emerging. 

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