Angina

BHF factfiles

Management of stable angina: summary of NICE guidance (2011)

N0orthumberland Heart Health programme Stable angina

Northumberland guidelines 1999

Footnotes:

An exercise test is a poor diagnostic test in patients with low risk of CHD. There is a high risk of false positive results.
Even when the diagnosis of angina is clear further investigation is appropriate for most patients.
Patients with proven coronary artery disease and stable symptoms may not need further investigation if revascularisation is not wanted by the patient or is considered inappropriate.
A negative exercise test does not exclude coronary artery disease, especially if performed while taking anti-anginal medication.

CCS Score: Functional Classification of Angina

Class I Ordinary activity (e.g. walking, climbing stairs at own pace) does not bring on angina.
Angina occurs only with strenuous, rapid, or prolonged exertion at work or during recreation.
Class II Slight limitation of ordinary activity.
Symptoms occur when walking or climbing stairs rapidly, walking up a hill, walking up stairs after a meal, in cold weather, in wind, or when under emotional stress, or only a few hours after waking, and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.
Class III Marked limitation of ordinary activity.
Symptoms occur after walking 50-100 yards on the level, or climbing more than one flight of ordinary stairs in normal conditions.
Class IV Inability to carry on any physical activity without discomfort.
Angina may be present at rest.

When recording stability, establish whether the angina/chest pain has worsened in the last 3-6 months (change in frequency of pain, severity, duration, response to GTN, brought on by less than normal activity, the appearance of ‘new’ pain at rest). Remember to review this in the context of any change in mobility, i.e. angina may have improved because the patient cannot walk due to pain.

Efficacy of different strategies in patients with chronic stable angina

Intervention	Mechanism of action	Effect on:
Intervention	Mechanism of action	Angina	Myocardial infarction	Strokes	Revascularisation	Mortality
PCI with stents	Tackles discrete stenoses	Reduced	None	None	May increase repeat procedures	None
CABG surgery (left main and 3 vessel disease)	Bypasses proximal stenotic segments	Reduced	Uncertain	Possibly increased	Low rate	Reduced
Lifestyle modification:
Smoking cessation	Prevents atherothrombosis	Uncertain	Reduced	Reduced	Uncertain	Reduced
Healthy diet	Prevents atherothrombosis	Uncertain	Reduced	Reduced	Uncertain	Reduced
Moderate physical activity	Prevents atherothrombosis	Possibly reduced	Reduced	Possibly reduced	Uncertain	Reduced
Drugs:
Lipid lowering agents	Prevent atherothrombosis	Reduced	Reduced	Reduced	Reduced	Reduced
ACE inhibitors	Prevent atherothrombosis	Possibly reduced	Reduced	Reduced	Reduced	Reduced
β blockers	Stabilise plaque; reduce oxygen demand	Reduced	Reduced	Uncertain	Possibly reduced	Reduced
Antiplatelet agents	Prevent thrombosis	None	Reduced	Reduced	None	Reduced

ACE=angiotensin converting enzyme; CABG=coronary artery bypass surgery; PCI=percutaneous coronary intervention.

Management of stable angina: summary of NICE guidance (2011)

Management of stable angina: North of England guidelines 2001

Summary
Introduction
Scope of the guideline
Treatment