Refractory angina (RA) is a growing clinical problem due to improved survival from coronary artery disease (CAD) and an ageing population. These no option patients experience chronic angina-type pain, in the context of CAD, despite optimal medical and revascularisation therapies. Consequently, management of these patients is challenging and outcomes remain suboptimal. As mortality is no worse, the focus of treatment has shifted to improving symptoms, quality of life (QoL) and psychosocial outcomes.Methods
We undertook a single-centre study of the impact of a multi-disciplinary care pathway (Figure 1) on psychosocial outcomes, QoL and changes in cardiovascular medications. We performed a retrospective search of Electronic Patient Records and databases at the Royal Brompton Hospital for all patients with RA seen between 23/01/2003 and 06/06/2016. Data collected included pre- and post-intervention Hospital Anxiety and Depression Scale and Seattle Angina Questionnaire scores, use of the Angina Plan, referral for specialist pain management and alterations in cardiovascular medications. Median scores and differences for anxiety, depression and QoL were analysed using Wilcoxon matched-pairs signed rank tests. Chi-squared tests were used to assess medication changes. Statistical significance was p<0.05.Results
A total of 190 patients with RA were included. The Angina Plan was used in 80.5% (n=153) and 38.9% (n=74) patients were referred to pain clinic. Comparison of pre- and post-intervention scores (Table 1) showed significant improvements in anxiety (p=0.0005), depression (p=0.0469), and QoL including physical limitation, frequency and perception of angina symptoms and treatment satisfaction (all p<0.0001) (Figure 2). Nicorandil use was reduced (p<0.05) and ivabradine and ranolazine increased (p<0.0001). Other anti-anginal (ÃƒÅ¸-blockers, calcium channel blockers, long-acting nitrates) and disease modifying drugs (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, antiplatelets) were unchanged (p>0.05) (Table 2).Conclusions
In this study, we showed that a multi-disciplinary care pathway for patients with RA can significantly improve psychosocial outcomes, QoL and medication use. Furthermore, the rate of use of the Angina Plan was high, emphasising the benefits of this specialist nurse-delivered cognitive behavioural therapy-based rehabilitation program in the management of RA. Conventional anti-anginal medication use was largely unchanged or reduced (52.8% of patients), in keeping with a non-cardiac aetiology for a proportion of patients symptoms. Ivabradine and ranolazine increased, associated with their introduction to the market. Few data demonstrate the potential impact of specialist services for patients with RA in improving QoL and psychosocial wellbeing, which are the management priorities in this challenging patient group. Our findings suggest that further work in this area is warranted.