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Stable Angina: Methods, Evidence & Guidance [Internet]

Stable Angina: Methods, Evidence & Guidance [Internet]

NICE Clinical Guidelines - National Clinical Guidelines Centre (UK)

Version: July 2011

Secondary prevention

The aim of treatment for people with stable angina is to reduce symptoms suffered by patients and also to improve long term outcomes. Secondary prevention measures are important to reduce the progression of cardiovascular disease and are of established benefit for patients in certain circumstances e.g. post myocardial infarction – NICE Clinical Guideline 48 MI: Secondary prevention. NICE have also published a guideline NICE Clinical Guideline 67 Lipid modification which recommends statins for all patients with evidence of cardiovascular disease. This review therefore examined the evidence for use of aspirin and ace inhibitors in people with stable angina.

Guideline summary

The care pathway is summarised in the following pages. For a more detailed version, please refer to the quick reference guide for stable angina, which is available from www.nice.org.uk/guidance/CG126/QuickRefGuide

Methods

This guidance was developed in accordance with the methods outlined in the NICE Guidelines Manual.

Risk scores

The GDG were interested in whether there were scoring systems available that would predict adverse outcomes. Ideally clinicians would like to be able to predict which patients were likely to have an adverse outcome and to intervene in those patients. In the absence of clear evidence for benefit of pharmacological or revascularistion strategies this might mean providing more intensive education and rehabilitation and support programmes to help patients to engage in secondary prevention strategies.

Cardiac syndrome X

Cardiac syndrome X can be defined as angina in the presence of normal coronary arteries. Diagnostic criteria may also include evidence of ischaemia. The term microvascular angina is also used as it is thought that the pathology may lie within the microvasculature. Abnormalities of endothelial function have also been described.

Other anti anginal drugs and general drug recommendations

Ivabradine, nicorandil, and ranolazine are anti-anginal drugs that are licensed for use in the treatment of stable angina. The GDG were interested in evidence for the use of these drugs either as monotherapy or in combination with other anti-anginal drugs, and their place in the pathway for people with stable angina.

Medical versus revascularisation interventions

This chapter compares the effectiveness of medical treatment to revascularisation (PCI or CABG) for treating people with stable angina.

Functional and anatomical investigations

NICE Clinical Guideline ‘Chest pain of recent onset’ emphasizes the importance of clinical assessment in establishing a diagnosis in people with chest pain. When the diagnosis is uncertain functional tests for the demonstration of inducible myocardial ischaemia and anatomical tests to confirm the presence of obstructive coronary artery disease are also recommended.

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