National Institute for Health and Clinical Excellence (NICE)
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New NICE guideline says drug therapy should come before interventional procedures for people with stable angina
NICE has today (1 August) published its clinical guideline on the management of stable angina. The guideline, which has been jointly developed by the National Clinical Guideline Centre for Acute and Chronic Conditions (NCGCACC), sets out recommendations on what treatment and care the NHS should offer to people with a diagnosis of stable angina, including the use of anti-anginal drug treatment and surgery.
Stable angina is a chronic medical condition with a low but appreciable incidence of acute coronary events and increased mortality. The aim of management, which includes lifestyle advice, drug treatment and revascularisation (interventions to clear blocked arteries using minimally invasive or surgical techniques), is to stop or minimise symptoms, and to improve quality of life and long-term morbidity and mortality.
Key recommendations in the guideline include:
Offer people optimal drug treatment (one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease) for initial management of stable angina.
Consider revascularisation - coronary artery bypass graft (CAGB) or balloon angioplasty (also called percutaneous coronary intervention PCI) - for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment.
When either procedure would be appropriate, explain to the person the risks and benefits of PCI and CABG for people with anatomically less complex disease whose symptoms are not satisfactorily controlled with optimal medical treatment. If the person does not express a preference, take account of the evidence that suggests that PCI may be the more cost-effective procedure in selecting the course of treatment.
When either procedure would be appropriate, take into account the potential survival advantage of CABG over PCI for people with disease in more than one artery whose symptoms are not satisfactorily controlled with optimal medical treatment and who:
have diabetes or
are over 65 years or
have anatomically complex three-vessel disease, with or without involvement of the left main stem.
Ensure that there is a regular multidisciplinary team meeting to discuss the risks and benefits of continuing drug treatment or revascularisation strategy (CABG or PCI) for people with stable angina. The team should include cardiac surgeons and interventional cardiologists. Treatment strategy should be discussed for the following people, including but not limited to:
people with left main stem or anatomically complex three-vessel disease
people in whom there is doubt about the best method of revascularisation because of the complexity of coronary anatomy, the extent of stenting required or other relevant clinical factors or comorbidities.
Professor Peter Littlejohns, NICE Clinical and Public Health Director, said: “An estimated two million people in England have either had or currently have stable angina. Although there are effective treatments, there has been a great deal of uncertainty about the appropriate management strategies. The guideline development group has carefully weighed all the current evidence and NICE considers that implementation of this guidance will improve patient care by allowing clinicians and their patients to make an informed decision in individual circumstances.”
Professor Adam Timmis, Professor of Clinical Cardiology and Chair of the Guideline Development Group, said: “The main impact of this guideline will be its emphasis on ‘optimal medical treatment' - OMT - as the initial treatment strategy for all patients with angina, with PCI and CABG reserved principally for patients who remain symptomatic. No longer will it be acceptable to undertake these revascularisation procedures in patients not receiving anti-anginal and secondary prevention treatment as detailed in this guideline. The guideline's symptom-driven approach to revascularisation, without the need for routine ischaemia testing, will be welcomed as acknowledging that the principal benefit of revascularisation is in relieving symptoms. A further impact on clinical practice will be the recommendation that choice of revascularisation procedure should be determined by a multidisciplinary team comprising cardiologists and cardiothoracic surgeons, particularly in those patients where the symptomatic argument for revascularisation is complicated by prognostic considerations. Whatever the choice arrived at by the multidisciplinary team, the guideline recognises that it should be properly discussed with the patient in order that he or she can make a fully informed contribution to the decision.
He continued: “The guideline development group recognised that prognosis is generally good in the large group of patients whose symptoms respond well to OMT, but that a minority will have high risk coronary anatomy. The recommendation that the risks and benefits of further investigation and possible CABG (there is no indication for PCI in this asymptomatic group) should be fully discussed before proceeding will further reduce the need for non-invasive ischaemia testing, as many patients informed of the evidence will doubtless choose to continue with OMT.
“It is ironic that the most radical aspects of this new guideline are its recommendations for a more conservative evidence-based approach to the management of angina.”
Dr Jonathan Shribman, GP with a Special Interest in Cardiology and member of the Guideline Development Group, said: “This guideline clarifies the evidence- based management for stable angina and makes very clear who should be offered revascularisation and who should not.”
Mr Christopher Blauth, Consultant Surgeon and member of the Guideline Development Group, said: “People with stable angina need complete and accurate information about all the modalities of treatment available to them so that they can make choices which best meet their expectations for their future health and lifestyle. When revascularisation is considered, NICE guidance rightly promotes multidisciplinary team working to encourage specialists to collaborate in giving the best advice for each individual. Ultimately the choice between the convenience of percutaneous intervention and the superior durability and sometimes prolonged survival with bypass surgery should be made by the individual.”
Dr Maurice Pye, Consultant Cardiologist and member of the Guideline Development Group, said: “The guideline makes it clear that the management of stable angina is predominantly drug therapy, lifestyle modification and secondary prevention. The role of revascularisation is principally for patients with limiting anginal symptoms resistant to drug therapy.”
Helen O'Leary, Angina Clinical Nurse Specialist and member of the Guideline Development Group, said: “The guideline makes a number of important recommendations about the need to engage with patients at every step of the journey. In particular this should ensure that patients fully understand, and are involved in, discussions about the benefits, limitations and risks of continuing drug treatment, CABG and PCI to help them make an informed decision about their treatment. The guideline also highlights where there are gaps in the evidence to support best practice for patients with stable angina, and signposts the way for essential, relevant, research projects.”
Roger Till, patient/carer representative on the Guideline Development Group, said: “I was very impressed by the thorough and thoughtful analysis that went into this guideline. I am particularly pleased to see the strong emphasis given to ensuring that patients and carers are given the necessary time and opportunities to have their illness explained clearly. This is my first time as a patient representative on a NICE Guideline Development Group and it was a very positive experience.”
A suite of supporting information is available to help with the implementation of this guideline. This includes a factsheet on revascularisation for stable angina, a chest pain algorithm linking together the diagnosis, treatment and management algorithms from chest pain of recent onset (CG95), unstable angina / NSTEMI (CG95) and the stable angina guideline, a slide set and a costing statement.
Notes to Editors
About the guideline
1. The guideline is available at www.nice.org.uk/CG126
About stable angina
2. Stable angina is a chronic medical condition that can have a significant impact on quality of life. It is predictable chest pain or discomfort that typically occurs with activity or stress and is caused by poor blood flow through the blood vessels of the heart.
3. The condition affects up to 14% of men and 8% of women aged between 65 and 74 years, and is usually caused by coronary heart disease, a condition in which blood vessels in the heart become narrowed by a build up of fat. This reduces the supply of blood and oxygen to the heart. The most common symptom of stable angina is pain or a feeling of discomfort or tightness in the chest, which can often spread to the jaw, back, shoulders and arms.
4. An attack of angina can be brought on by anything that requires the heart to work harder, such as physical activity, emotional stress, exposure to cold or eating a heavy meal. The pain usually lasts for only a few minutes and goes away with rest. If left untreated, stable angina can progress to acute coronary syndrome - a range of heart conditions from unstable angina to heart attacks.
5. The aim of management is to get rid of, or minimise symptoms and to improve quality of life and long-term morbidity and mortality.
6. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.
7. NICE produces guidance in three areas of health:
public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS
8. NICE produces standards for patient care:
quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
9. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.