This section is mainly for GPs, so please forgive the jargon.
Many GPs are understandably nervous about taking on angina patients who would normally be treated by hospital “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 fact is, for good or ill, primary care teams play an important part in the management of chronic angina. Many patients receive the sort of help and support they need. Unfortunately for some, lack of training and time means that often GPs and other healthcare professionals inadvertently contribute to the problems by reinforcing harmful misconceptions. Many healthcare professionals share patients’ common misconceptions about angina and its treatment. For example a significant minority assume that repeated episodes of angina damages the heart and most are unaware that angioplasty for stable angina has no beneficial impact on survival.
The ‘trick’ to managing patients with stable angina is to recognise that it is an ischaemia-related chronic visceral pain syndrome in which harmful misconceptions leading to fear, anxiety, depression and unhelpful health behaviours play an important role. In our experience patients and their carers are capable of extraordinary misunderstandings and misconceptions. Like all chronic pain conditions there is ample opportunity for the doctor to play a role in the progression of the syndrome. It isn’t necessary to be an expert. Sometimes it is enough to explain why a harmful misconception, such as “angina damages the heart,” is simply not true.
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. Once the diagnosis has been made it would be helpful to arrange to see the patient and their carers in order to help them 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 learned 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. This would only be valid if the anti ischaemia interventions were safer and more cost effective than the non invasive strategy of optimal medical management. GPs are often shocked to learn that angioplasty for stable angina is offered for purely symptomatic reasons and the cost per quality of life year gained (QALY) exceeds the generally accepted threshold by 1.5 to 3 fold. They are equally shocked to hear that the relatively small and usually temporary symptomatic improvement could be explained by placebo, since there has never been an attempt to examine the contribution of the placebo effect in angioplasty. Two placebo studies showed that tying off the internal mammary artery (IMA) and pretending to tie it off were equally effective in relieving angina. Tying off the IMA has no effect on coronary ischaemia, so the studies were comparing a sham with a sham-sham procedure. It is striking that over 60% of the angina sufferers who enrolled in the studies, experienced clinically significant improvement in angina for many months, irrespective of whether they were in the sham or the sham-sham arm of the trials. It is also striking that the clinical benefits through placebo substantially exceeded those presently seen with angioplasty.
Evidence-based comprehensive patient-centred care programmes designed to promote self-management regularly produce profound improvements in the patients quality of life at lower cost and lower risk than palliative revascularisation should represent a major challenge to the conventional treatment model. However, presently, patient-centred care is relegated to last place in the care pathway. The notion that education and relaxation training must be reserved until after a trial of expensive, dangerous palliative revascularisation of doubtful benefit is a logical absurdity on all counts. Moreover when there are no justifiable clinical grounds for withholding information about these low risk alternatives, it breaches good practice guidelines, EU law and proper consent practice.
The greatest obstacle to patient-centred care is the lack of effective role models. Despite their training in patient-centred interviewing, GPs, who are used to spending ten minutes with a patient, feel very uncomfortable at the idea of spending up to two hours with a patient and carer. In our experience, a period of theoretical and practical training is required before doctors are able to deliver optimal patient-centred angina care. Once they see a real time example of a patient-centred interview GPs quickly realise that it is the only effective way to manage these complex patients and that their training has already prepared them for patient-centred interviewing. A service delivery model that recognises the clinical value of a genuinely satisfied customer ensures that the service continues to evolve and improve. Link to Virtual Angina training programme.
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, the agreed objectives and the proposed strategy is necessary to minimise misunderstandings and avoid confusion. It also means the patient’s relatives are more likely to actively engage in the process and this is important in most situations.
- Book a longer than average appointment with patient and carers: these families are depressed, anxious and confused and there is a lot to do. Anxiety and depression are notorious obstacles to cognition and you have to begin the process of relieving anxiety before you can reasonably expect new ides to ‘stick.’ Write to the consultant and ask them to confirm that revascularisation is not required to improve life expectancy. That is a very straightforward request and should not be difficult to answer.
- 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. The current NICE endorsed Royal College of GP guidelines on medication compliance (http://guidance.nice.org.uk/CG76) emphasises the importance of developing a therapeutic patient centred alliance.
- 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.
- 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.
- 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.
- Angina and collaterals: A shortfall in blood supply to the heart muscle triggers adaptive responses: the release of protective ‘preconditioning’ proteins; and the growth of new vessels and the establishment of collaterals. Activation of the angina pathway is an accidental by product. It certainly helps the patient to relax if they realise that whilst angina may hurt, it also signals that the heart is protecting itself.
- Give simple relaxation advice: Withdrawing excess catecholamines is extremely helpful in angina and can be achieved by replacing anxiety promoting misconceptions with positive thoughts coupled with muscle relaxation and breathing exercises.
- 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. Unfortunately, harmful misconceptions about the dangers of exercise are commonplace, so it is important to elicit the patient’s and carers’ beliefs before trying to persuade them to do something they might regard as dangerous.
- Undertake a cardiovascular risk assessment and engage the patient and their carers in tackling modifiable risk factors.
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 too brief meeting with an inexperienced trainee doctor. On the other hand, patients often complain that they receive conflicting information from different healthcare professionals and that this adds to their sense of frustration. If it has already been decided that there is no likelihood of a life-prolonging procedure, the benefits of attending a standard cardiac outpatient clinic are minimal for most patients. It is worth asking the patient how much benefit they think they get out of their outpatient visits. A surprising number will say that their usual experience is that it is a waste of time.
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.
Follow the link for specialist patient-centred angina clinics.