Patient version

Care pathways or guidelines help doctors and patients with complex problems decide what to consider next when there are many different treatment options. Care pathways developers try to sort out which treatments should be included in the pathway and then set them out in a logical order.

In 1996, when we set up the first patient-centred angina clinic for so-called “end-of-line” angina sufferers we weren’t sure where to start. We contacted several of the top UK experts to find out what they thought should be done to help a patient who still had angina despite multiple angioplasty procedures and two bypass operations. One expert suggested it might be worth trying a TENS machine, another suggested a third bypass while another said, “there’s always something you can unblock with a angioplasty balloon.” One suggested a nerve injection and another suggested a heart transplant. A psychologist who specialised in angina asked if we knew what the patient thought was going on and what they really wanted. This turned out to be the most sensible suggestion.

Each expert suggested the treatment they were personally familiar with. The worrying thing was that the interventional experts didn’t suggest trying something simple and non-invasive first. They didn’t seem to understand that if patient is offered a third bypass he will naturally assume that there couldn’t be a simple low risk alternative. The result was that the same patient could travel around the country and meet half a dozen different experts and receive half a dozen opinions on what should be done, ranging from simple outpatient treatments up to a heart transplant. In practice patients tend to stick with who they know and the result is that patients who go back to their bypass surgeon are very likely to end up with another bypass, even if they would have preferred to try something low risk first.

It was clear to anyone that a care pathway was urgently needed and we persuaded a group of national and internationally renowned experts to come together to agree what should be included in the pathway. In a major innovation, we asked patients to tell the experts what mattered most to them. It won’t surprise patients that the patients told us they wanted a better quality of life for themselves and their families. They also told us they would prefer to hear about low risk, non-invasive treatments before invasive procedures. They also said that if they had to take risks of a complicationfrom an invasive procedure they would prefer to hear about treatments with reversible complications first. This helped the expert panel to sort out the various treatment options into a sensible order with the least invasive options listed before the more invasive ones.

NRAC implemented the care pathway in 1999 and we have modified the pathway to take account of new research and patient preference.

Everyone agrees that the pathway should start with a holistic diagnosis to ensure the doctor understands how the condition affects the patient and their family. Doctors who don’t understand how the condition affects the patient and their family can easily miss simple interventions that could significantly improve things.

After that patients should be educated about the condition and the risks and benefits of the available treatments. This is a time consuming process that is only available at specialist patient centred angina clinics where patients learn how to work with their doctors to get the best out of life. Getting the best out of life generally involves learning stress management techniques, how to get fit and stay fit, changing to a healthy diet and getting on the right combination of drugs.  (Note, optimising drugs doesn’t necessarily mean taking more tablets. In practice patients who follow the programme are able to take fewer drugs).

Next, but only after the patient has completed the education programme, treatments are considered in the following order (patient-friendly information leaflets are provided):

• Transcutaneous electrical nerve stimulation (TENS).
• Nerve blocks.
• Spinal cord stimulation (SCS) for nerve damage pain.
• Strong pain killers.
• Enhanced External CounterPulsation (EECP).
• Acupuncture. (Acupuncture his is at the end of the list because there is very little research evidence, on the other hand, complications are extremely rare)
  

We recommend that the following invasive therapies should only be undertaken as part of a formal clinical trial.

Nerve destruction; Laser (via blood vessels, a bit like an angiogram, or via an operation through the chest); Gene therapy.

Angina alone is not an indication for cardiac transplantation.

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Jargon version

What follows is the current ‘consensus’ evidence linked treatment algorithm that has been commissioned by the United Kingdom Pain Society. The guideline has been endorsed by the British Cardiovascular Interventional Society and reflects the current ’state-of-the-art’  (see National Health Service, National Service Framework Document for Cardiology, March 2000, chapter 4, p6, paras 16-17).

Working guideline

This document is designed to open the debate to a wide audience on the “best management stepwise algorithm” for patients suffering with chronic refractory angina.

This is a menu of treatment options that an average patient would wish to know about before choosing the one that is best suited to their particular circumstances. The order reflects patient preference for low risk reversible options before high risk invasive procedure. Not all options will be available outside specialist clinics and individual practitioners will have to take account of local resource provision when discussing options.

Comprehensive biopsychosocial diagnosis.

1. This should include a diagnosis of the physical problem and the emotional and social consequences. A significant minority of angina patients are misdiagnosed and have other pain conditions that confuse the clinical picture and assessment by a specialist pain is invaluable. Anxiety promoting misconceptions are very common among patients and carers and often lead to harmful behaviours. Identifying health misconceptions is a time consuming but necessary part of optimal medical care.  We recommend established questionnaires such as the Hospital Anxiety and Depression inventory (HAD), the Angina Plan questionnaire or the simple 5 point Liverpool Angina Questionnaire to quickly identify problems.
2. It is essential that realistic and achievable objectives and a working strategy is agreed at the outset.

Rehabilitation. Based on recommended guidelines: involving education, risk factor modification, optimisation of medication and stress management. This is most effectively delivered through group cognitive behavioural therapy techniques.

Multidisciplinary cognitive behavioural intervention programme. If appropriate-based on established psychological assessment methods e.g. Hospital Anxiety and Depression score. A formal psychological assessment can be of value especially in determining whether formal psychotherapy may be of value.

• Transcutaneous electrical nerve stimulation (TENS).
• Temporary sympathectomy. Stellate ganglion block, T3/4 paravertebral block in stages. High thoracic epidural. Based on the Liverpool protocol. These provide temporary relief and require repeated treatments.
• Spinal cord stimulation (SCS). In 2009 NICE decided that there was insufficient evidence for cost effectiveness to justify the continued use of SCS for angina. SCS does have a role in nerve damage related pain (neuropathic pain) that commonly complicated bypass surgery.
• Opioids. Should only be prescribed by specialist opioid clinics after extensive counselling and in close communication with the GP.
• Enhanced External CounterPulsation (EECP). This is only available in a very limited number of specialist centres. It involves over 35 hours of treatment delivered on average for an hour and a half a day. A standard course of treatment requires daily hospital visits for five to seven weeks.
• Acupuncture. There is very limited research evidence for acupuncture but it is simple and low risk and is often preferred to the options that follow.

We recommend that the following invasive therapies should only be undertaken as part of a formal clinical trial.

Destructive sympathectomy (thoracoscopic, surgical or phenol); Intrathecal opioids; Myocardial laser (percutaneous or transmyocardial); Gene therapy.

Angina alone is not an indication for cardiac transplantation.

For more information, queries or comments please contact Prof. M Chester.