CARE PATHWAY
What follows is the current ‘consensus’ evidence
linked treatment algorithm that has been commissioned by the United Kingdom Pain Society and the British
Cardiac 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).
The final guideline document will be produced following a year long extensive consultation process in 2000.
Draft 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. The
authors stress that it is a draft proposal and that
individual practitioners will have to take account of
local resource provision.
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*Outpatient counselling to
include explanation of management plan, lifestyle
advice (diet, smoking, physical activity. It is essential
that a realistic and achievable ‘treatment
contract’ should be decided on so that the
patient, their family and the clinical treatment
team have an agreed objective.
-
*Rehabilitation. Based on recommended guidelines:
involving exercise programme, lifestyle advice,
relaxation training.
- *†Multidisciplinary cognitive
behavioural pain management 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
- †Spinal cord stimulation (SCS).
Implant data and outcome should be recorded in a registry.
- *†Opioids. There is limited evidence of the
effectiveness of opioids in refractory angina. In
clinical practice oral and transdermal opioids
can be effective. Trial of epidural followed by
†intrathecal opioids might be beneficial.
- †Destructive sympathectomy. Thoracoscopic, surgical, phenol
depending on local expertise.
- †Myocardial laser (percutaneous or transmyocardial). There
is insufficient data to support this therapy
outside clinical research. We recommend that
these therapies should only be undertaken as part
of a formal clinical trial.
- Angina alone is not an indication for cardiac transplantation.
NOTE: *
can easily be undertaken in appropriately
resourced district general hospitals, † should be performed only in specialist
centres. Also, new therapies such as external
enhanced counterpulsation (EECP)
therapy will be considered at the next guideline group meeting.
Recommendations
-
‘Refractory angina’ as
proposed above is a pragmatic diagnosis in the
absence of an agreed definition. A consensus view
by the profession will be sought through
consultation
-
Closer links between cardiologists
and pain specialists is essential.
-
There is a striking lack of
randomised controlled trials (RCTs) in this area.
Clearly a great deal of research is required.
There is an overwhelming case for comparative
studies.
-
The UK National refractory angina
guideline group are working with overseas
organisations to encourage them to adopt these
guidelines (EFIC, ESC, APS, IASP, ISC).
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