Chronic Refractory Angina

The Primary Care Team

Primary care teams have an important part to play in the management of chronic refractory angina. Unfortunately many GPs appear to be intimidated by the complexity of a clinical problem that has already confounded the "specialists".  Patients and their carers often say "our family  doctor is very kind but what can he do when even the specialist says that there is nothing more he can do?"

The trick to managing patients with chronic refractory angina is to recognise that it is an ischaemia-related chronic visceral pain syndrome in which fear, anxiety and depression play an important role. Like all chronic pain conditions there is ample opportunity for the doctor to play a role in the progression of the syndrome.

A clear example of this is when the patient is told by the cardiologist or cardiac surgeon "there is nothing more that I can do". Nearly every patient says that it was one of the lowest points in their life. Thus once the diagnosis has been made and no sensible treatment options offered  it would be helpful to arrange to see the patient and their carers in order to regain their confidence and develop a treatment plan.

The phrase "there is nothing more that I can do" is not the same thing as "there is nothing more that can be done" but that is commonly what patients think it means. This is partly because the cardiac patient has become conditioned to believe that the revascularisation strategy is the only strategy.

 After 2 or more bypass procedures and umpteen angioplasties patients can hardly be blamed for asking "if simple alternatives exist then why weren't they tried earlier?" The real reasons for this are complex and have to do with the prevailing disease-centred treatment paradigm in which the anti-ischaemia approach to the management of chronic disabling angina is considered the only justifiable way to treat patients and that alternative pain management techniques should be reserved as a treatment of last resort once that anti-ischaemia treatment possibilities have been exhausted.

The fact that a simple explanation of the condition, cardiac rehabilitation, relaxation techniques and transcutaneous electrical nerve stimulation (TENS) can produce profound improvements in the patients quality of life represents a major challenge to the conventional treatment model. The notion that relaxation training must be reserved until after a trial of redo revascularisation is a logical absurdity on all counts except in the increasingly rare situation when redo revascularisation can realistically increase life expectancy.

The process of rehabilitation begins with agreeing realistic goals and is based on a proper understanding of the pathogenesis of the condition. Too much information can overwhelm the patient so the first visit should simply set out the aims and briefly outline the strategy.  A patient information sheet on angina and the treatment guideline can be helpful.

Proposed checklist

1. Book a longer than average appointment with patient and carers: these families are depressed, anxious and confused and there is a lot to do.
2. Check that treatment is optimal: Don't assume that maximal and optimal are one and the same. Many patients can be improved by cutting out or reducing drugs that are producing unacceptable side effects. It is always worth reducing medication slowly in stages especially beta blockers.
3. Explain that the aim of treatment is to improve the patient and their families quality of life and that there are several simple options that are effective.
4. Explain the nature of angina: Angina pain is not the same as pain from the skin or joints and it does not obey the same rules. A simple thought experiment can be used to illustrate this by asking the patient to imagine walking out of the office with a small stone in their shoe. Nearly invariably the patient will say that they would be aware immediately, know what it was and which shoe. Compare that to their experience with coronary heart disease, especially when the resulting angina has extensive radiation. Patients readily acknowledge that they have difficulty describing the pain and that it took a period of time before the diagnosis was made even after they sought medical advice. That is because the heart does not have "specialised pain nerves" like the skin. The body had to "construct" the angina nerve before the brain could receive the signal and it uses the existing nervous system. The new pathway often uses the arm nerves or jaw nerves so it is not the brain fault that it makes a mistake. Unfortunately once created the "angina" pathway develops amplification units along its course so that over time even a tiny stimulus can be amplified to provoke severe pain. Most patients have experienced the situation when a severe episode of angina is not accompanied by ECG changes and usually found that perplexing. This can now be explained by the fact that the ECG cannot register minute amounts of ischaemia but the nerve can. Even worse the fight or flight response feeds back to the heart and invariably makes the problem worse.
5. Angina does not wear the heart out: It is remarkable how many patients think that each episode of angina is a mini heart attack and consequently avoid anything (e.g. exercise) that might bring on an attack. Avoidance behaviour can limit activity and is often reinforced by the patients carers who frequently accelerate the deterioration of the condition by preventing their loved ones from even gentle exercise.
6. Angina and collaterals: Myocardial ischaemia encourages the growth of new vessels and collaterals at the same time as activating the pain pathway and it certainly helps the patient to relax if they realise that whilst angina may hurt it also signals that new blood vessels are growing.
7. Give simple relaxation advice: Withdrawing excess catecholamines is extremely helpful in angina and can be achieved by muscle relaxation and breathing exercises.
8. Emphasise the importance of regular gentle exercise: the evidence for the beneficial effects of lifestyle changes and regular exercise in improving quality of life is clear.

It may also be worth making a formal request to the cardiac specialist for the patient to be seen in the new patient clinic once the diagnosis has been made. This will ensure that the patient will have extra time to discuss important issues with a senior experienced clinician rather than the often unhelpful and all to brief meeting with an inexperienced junior.

Chronic refractory angina has been badly neglected and the complexity of the problem requires a multi disciplinary approach involving professional groups such as pain specialists, psychologists and rehabilitation teams who do not interact closely with cardiologists and cardiac surgeons. The primary care physician can use his/her influence to encourage the development of multi professional groups with an interest in refractory angina. 

A list of specialist centres with an interest in refractory angina will be available from January 2001.