Chronic Refractory Angina

*Patient centred treatment model

Chronic Refractory angina is a best described as an ischaemia related chronic visceral pain syndrome. Like so many chronic pain syndromes refractory angina cannot be cured and the majority of patients have already come to terms with that by the time the diagnosis has been made. However the effects of angina can be ameliorated and the patient's quality of life improved by applying a simple patient-centred model of treatment.
Once the diagnosis has been established it is essential for the physician (ideally part of a multidisciplinary team), the patient and their carers to reach agreement on desirable and achievable treatment objectives.

Treatment aims & the treatment contract

The primary aim of therapy is to maximise the patients quality of life by ameliorating the effects of the condition without jeopardising quantity of life. The patient and their loved ones need time and help to define how angina impairs their quality of life and what level of recovery would be acceptable. These are difficult concepts in the present medical system where patients have assumed an almost subsidiary role in a largely pathology or disease-based medical treatment paradigm. Thus chronic refractory angina patients will readily explain their symptoms and the effects of treatment in detail but are reluctant to get involved in the decision making process. This nearly always arises from the notion that "the doctor knows best" coupled with an understandable desire not to challenge medical authority. But how can the doctor know what the patient really wants unless he takes the trouble to ask?
All too often we see patients who have undergone or are under consideration for very high risk therapies without ever confirming that the surgeon's objectives were the same as the patients'. Very often they are not. The physician needs to listen to the patient and give an honest appraisal of the likelihood of improvement and the risks involved considering the various therapies available. In addition the majority of patients and carers experience high levels of anxiety and nearly invariably have erroneous beliefs about their condition. These ideas have to be explored, explained and realigned where necessary and this takes time, patience and appropriate training.  
The usual brief visit to routine cardiac outpatient clinic is simply not adequate for chronic refractory angina management.  The ideal doctor/patient relationship exists when the patient, their carers and doctor can openly 'negotiate' a treatment contract with clearly stated aims and objectives. In this way the choice of therapy becomes simplified for the doctor and it enables the patient to make more rational decisions about which therapy is most appropriate to his/her particular needs.

*Editors note. Just because "patient centred treatment model" sounds "politically correct" it doesn't necessarily mean that it is wrong

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