Chronic Refractory Angina

Diagnosis

Chronic refractory angina is a clinical diagnosis. It is based on the presence of symptoms of stable angina that are thought to be caused by ischaemia due to advanced coronary disease and which are not controllable by a combination of maximal anti anginal medication, angioplasty or coronary artery bypass surgery. The presence of demonstrable myocardial ischaemia is desirable but is not an absolute requirement for including a patient in the guideline process. As the patient moves through successive stages of the treatment algorithm it becomes increasingly important that ischaemia is confirmed especially when high risk, high cost procedures are considered. The choice of investigation must be at the discretion of the individual clinician considering local expertise and availability and the level of confidence in the clinical diagnosis.

2004 Update

The original November 1998 definition of chronic refractory angina left open the possibility that patients with chronic stable angina might be denied a diagnosis of chronic refractory angina simply because revascularisation was technically feasible. Feasibility is a purely technical decision and is not synonymous with appropriate. Valid consent practice should ensure that patients are informed of all available treatment options (including no treatment) so that they can select the most appropriate one for themselves and their carers. However we recognised that some clinicians might mistakenly believe that all available treatments should only be offered to patients only after it had been decided that revascularisation was not an option. This confusion could lead to patients being denied an opportunity to consider low risk alternatives to palliative revascularisation because revascularisation was deemed feasible. This approach is risky for patients and clinicians. In our experience it leads to patients undergoing procedures that they might have avoided if they had had an opportunity to choose from lower risk options. Failure to inform patients about the range of options available for their condition invalidates consent and leaves open the possibility for negligence claims.

At the May 1999 the UK national guideline group meeting it was decided to clarify the definition. The current UK national chronic refractory angina guideline group’s definition of chronic refractory angina is, “Chronic stable angina that persists despite optimal medication and when revascularisation is unfeasible or where the risks are unjustified.”

This definition was fully implemented at the UK NHS National Refractory Angina Centre in June 1999 and was formally adopted by the UK Pain society angina special interest group in March 2000. It reflects current best consent practice and requires clinicians to involve patients fully in choosing from all the available therapies the one that is best suited to their needs. In practical terms, this definition has little or no impact on the outcome of consenting a patient with a tight left mainstem, proximal three-vessel disease or proximal left anterior descending disease. It does have a significant effect on the process of obtaining valid consent for palliative revascularisation for which low risk alternatives exist (see discussion pages)

Requirements

1. Diagnosis requires a cardiological and cardiothoracic surgical opinion that the patient has angina of ischaemic origin and that revascularisation is unfeasible or where the risks are unjustified. Regular angiographic review is recommended to exclude the development of ‘new’ revascularisable disease.
2. Outpatient assessment to include: Review of pain history, drug history and physical exam. It is essential to ensure that the patient has failed to respond to optimal medication. Poor compliance should be considered and the need for compliance explained. Simplification of the drug regimen is recommended. Maximal medication should not be confused with optimal. Very often medication side effects can be worse that the symptoms the drug was prescribed for.
3. Exclude non-cardiac causes e.g. costrochondritis, intercostal neuralgia, anaemia, thyrotoxicosis, reflux oesophagitis (consider trial of proton pump inhibitors). Patients frequently suffer chest wall pains related to previous cardiac surgery and this can be confusing for the cardiologist. Specialist review by pain physicians can be helpful.  Very often the patient can distinguish between angina and "scar" pains and it is important to tackle both pains if they both contribute to the patients reduced quality of life.
4. Fear, anger and frustration) based on simple misunderstanding is very common in angina sufferers. Fear and inappropriate avoidance behaviour often dominate the clinical picture. The 2002 updated AHA/ACC guidelines on stable angina management emphasises the importance of patient and carer education.
5. It is important that consider the possibility that depressive disease may contribute a significant component to their total pain experience. The HAD questionnaire is a simple screening tool that can help to identify patients who might benefit from psychiatric or psychological intervention.

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