Management of angina

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

What is the evidence?

• Most evidence suggests a beta-blocker should be the first-line prophylactic agent for regular symptom control.
• Management options still being evaluated include spinal cord stimulation and transmural myocardial laser revascularisation (Curr Cardiol Rep 2006; 8: 272-6).
• 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: 2,529-36).
• Women with angina often present differently to men. Cardiac investigations such as exercise ECG are less specific and less sensitive in women (BMJ 2005; 331: 467-8).
• Analysis of the IONA trial showed adding nicorandil to antianginal treatment is cost-effective as it leads to a lower incidence of cardiovascular disease (Heart 2006; 92: 619-24).

Implications for practice

• There are still wide variations in the quality of care given to patients with angina.
• A recent clinical review has highlighted that atenolol may be less useful than other beta-blockers, and other antihypertensive drugs, in reducing cardiovascular disease (CVD) in hypertensive patients (BMJ 2007; 334: 946-9). - A US study of men and women aged 45-84 years without clinical CVD showed only 40 per cent of patients with dyslipidaemia are reaching cholesterol target. Only about half of patients at high risk of CVD were treated with a statin (Circulation 2006; 113: 647-56).
• Most GPs now have access to chest pain clinics.

Available guidelines

• The SIGN guidelines say 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 treatment to relieve their pain and to reduce the risk of coronary events.

Useful websites

• www.bcs.com - British Cardiac Society
• www.pccs.org.uk - Primary Care Cardiovascular Society

Key points

• CHD is the most common cause of death in the UK.
• Many patients are still not reaching target cholesterol.
• New treatments for angina are emerging.

Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners' PasTest 2006'