Chronic Refractory Angina

The UK NHS National Refractory Angina Centre, 

Royal Liverpool & Broad green University Hospital NHS Trust, 

Liverpool. L14 3PE. 

United Kingdom.

Telephone: +44 -151 293 2244/2448 Fax: +44 -151 293 2216

Winners of the National NHS Nye Bevan Award for Modernisation and Innovation, 2000

Innovation team of the year 2002: Overall inners of National NHS Hospital Doctor award

Safety award 2003: Highly commended National NHS & Health Service Journal award

Service Excellence award 2003: Highly commended Unisys Management Today

Extraordinary Achievement award 2004: Highly commended, Northern NHS

Mission statement:

"To improve and harmonise the standard of care of patients and their carers with chronic refractory angina"

The UK NHS National Refractory Angina Centre (NRAC) is the largest specialist centre for refractory angina sufferers in the UK. Despite tremendous technical advances which enable interventional cardiologists and cardiac surgeons to treat more and more complex disease there are patients who cannot be treated by revascularisation. Audit of activity over the past decade has revealed a steady growth in a number of patients presenting with refractory angina at the CTC. In response to this problem in 1996 the we set up the first multi-disciplinary refractory angina research and treatment programme in the UK.

As part of the clinical management policy at the hospital we developed a process for producing practical local clinical guidelines. An essential part of that process involved a systematic literature review and consultation with colleagues both locally and at other specialist centres elsewhere in the UK and beyond. In 1997 we audited management strategies offered to refractory angina sufferers in the UK cardiologists and pain specialists. This revealed gross variation in clinical practice with little or no interaction between the clinical disciplines. Thus an individual patient presenting with RAP might be offered 8 different therapies depending on the interests and expertise of their consultant ranging from simple counselling through neuromodulation to cardiac transplantation. More importantly these therapies vary enormously in terms of cost, safety and efficacy. This variation in clinical practice is clearly unacceptable and properly developed and enacted practice guidelines should be the most effective way to improve this situation. Before Dec 1998 no practice guideline existed and a recent survey revealed that the vast majority of UK cardiologists and pain specialists who responded agreed that a practice guideline for refractory angina is desirable.

Global problem

The problem of chronic refractory is universal and growing. With few exceptions the disease-centred model of therapy is applied throughout all healthcare systems with the same outcome. Treatment is prescribed based on the interests and expertise of the clinician rather than tailored to the needs of the patient.   

An important starting point in the development of refractory angina guidelines must be an agreed definition of terms. Several interchangeable terms are in use: intractable angina, end stage angina, resistant angina and refractory angina. In order to avoid the confusion generated by this in March 1999 we proposed that an agreed definition for chronic refractory angina should be adopted. This term now has wide consensus support from International authorities and is the accepted term  for the IASP special interest group (International Association for the Study of Pain) and ESC (European Society of Cardiology)

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