Case study Chest Pain treating angina without a bypass or stent

Transcription

1 Case study Chest Pain treating angina without a bypass or stent Dr Clare Hawley Associate Specialist Cardiology Chesterfield Royal Hospital GPwSI for Angina Management Programme Hon Lecturer Cardiology University of Bradford for PwSI

2 Declaration of Conflicts of Interests In the past I have received honoraria/expenses for educational talks from: Bayer, Boeheringer Ingelheim, Lundbeck, Menarini, Pfizer and Takeda

3 George is a 58 year old alarm fitter April 2013 seen in RACPC 2 years of typical angina, dismissed as getting old Instructor at gym noticed high heart rates Risk factors: ex smoker, HBP, hyperlipidaemia, Dad MI age 55 Rx: Felodipine MR 5mg od, Simvastatin 40 mg od O/E: No other obvious cause for symptoms ETT: 7 mins got symptoms 2mm ST depression in V4 & 5 Recovery: TWI for 9 mins Diagnosis: Stable angina

4 Medical Management Secondary prevention Antiplatelet Statin Anti anginal GTN Beta blocker Exisiting: Felodipine MR 5mg od Simvastatin 40mg od New: Aspirin 75mg od Atenolol 50mg od GTN spray Remember this was 2013!

5 Angiogram - May 2013 LMS: unobstructed LAD: 30% proximal stenosis D1: 100% occlusion Cx: 70% mid vessel RCA: 95% mid & 95% post left ventricular branch RCA receives collaterals from LAD ECHO: normal LV function Told likely to need 2 stents MDT: Not suitable for stenting No prognostic indication for CABG but could do for symptoms Referred to Angina Management Programme (AMP)

6 More medication Felodipine increased Isosorbide MN added HR 58 bpm BP 138/78 Felodipine MR 10mg od Simvastatin 40mg od Aspirin 75mg od Atenolol 50mg od ISMN 60mg bd GTN spray

7 1 st Visit to AMP Attended with wife Lynne Situation: Chest pain getting worse despite 3 anti-anginals 3-4 episodes per week on exertion & when stressed Episodes lasted at least 15 mins with 9/10 severity Reluctant to use GTN because of headache 2 admissions with normal ECG & no troponin rise Off work, taking no exercise QOL: 50% frightened & frustrated

8 Beliefs & misconceptions Arteries furring up & pain due to build up of pressure Angina damages the heart like a mini heart attack Chest pain is the heart protecting itself People should their best to avoid bringing on angina A stent would fix his CAD & protect from a future heart attack Devastated no chance of stent not keen on bypass

9 What patients think-based on > hour discovery interviews 1 angina damages the heart (50%) like a mini heart attack (40%) angina is due to back pressure on the heart as it struggles to force blood past coronary narrowings the arteries are furring up so it is inevitable that in time they will block completely & that will be it it is important to avoid anything that brings on angina (82%) stents prevent heart attacks & increase life expectancy (90%) 2 1 Chester 2 Kureshi F. BMJ Sept 2014

10 CHD often presents dramatically (999 or 2ww RACPC) Management focuses on diagnostic investigations & heroic interventions (drugs, stents & bypasses) Chest pain causes fear & anxiety for patients & staff Patient education is often overlooked (not resourced) Most patients don t really understand their angina

11 What our patients & some colleagues don t know about chronic stable angina Angina doesn t damage the heart With the right treatment & lifestyle prognosis is good & mortality low >70% survive 9 years from diagnosis * Feels unpleasant but myocardial ischaemia promotes collateral circulation & ischaemic pre-conditioning Pain due to mix up of pain & messaging nerves Adrenaline makes pain feel worse & endorphins provide relief Symptoms are amplified by psychological factors & can be controlled by better understanding, relaxation & exercise *Henry TD. European Heart Journal 2013

12 The truth about treatments Secondary prevention long term benefit Anti-platelet Statins ACE-I (for some) Anti-anginals for symptom relief only Reduce O 2 demand by reducing heart rate, contractility or vasodilatation rather than increase blood supply (BB, CCB, ISMN, Nicorandil, Ivabradine, Ranolazine) May improve symptoms & QOL - evidence of benefit is limited Don t improve life expectancy or reduce CV events Medical treatment of stable angina. Manolis IJ Cardiology 220(2016)

13 Angioplasty & stents in stable angina Improve symptoms & QOL Fractional Flow Reserve helps inform which lesions to treat But Doesn t reduce death, MI, admissions or further revasc* Technology is improving but still not without risk Procedural complications - MI, CVA Late complications: in stent stenosis (4-20% in 1 st 6 months less if drug eluting) in stent thrombosis (1-2%) Requires dual antiplatelet therapy for up to 12 mo Initial Coronary Stent Implantation With Medical Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease: Meta-analysis of RCTsArch Intern Med. 2012)

14 CABG in stable angina Palliative CABG For symptom control only (70%of procedures) 90% effective 10 years: 40% have angina back Prognostic CABG Improves survival in people with: significant left main stem disease 3 vessel disease + left ventricular dysfunction (LVD) 2 vessel disease involving proximal LAD & LVD But Major surgery - complications occur in 2-4% Post op pain Re do surgery is much less effective & more risky

15 The truth about angina pain Disability is more closely related to health beliefs & misconceptions than the degree of myocardial dysfunction or perfusion * Reaction & response to pain depends on: what we think is happening what we believe the consequences will be personal memories of something similar reactions of others around us The poorly informed make bad healthcare choices Empowered & informed people do better * Foreman RD. Ann Rev Physiol 1999

16 Chester M & Lewin R

17 AMP initial consultation 2 hours with patient & partner Assess the person s symptoms & impact of on QOL Explore what they want & what stops them getting it Establish beliefs & misconceptions about angina Provide education about what angina is & isn t collaterals & ischaemic pre-conditioning pain & somatic nerve pathways importance of fear & anxiety in angina impact of other conditions

18 AMP 4 group sessions Teach people how to control their symptoms Thinking differently about angina (CBT) Using relaxation techniques Exercise - goal setting & pacing Discuss risks & benefits of medication, stents & CABG Motivational interviewing to support healthy lifestyle How to recognise a heart attack & deal with setbacks Refer some on to cardiac rehab programme Follow 6 weeks & 12 months

19 George s story Jan 2014: feeling much better saw cardiologist d/c Dec 2014: just 2 episodes of angina in 6 months, not used GTN, more relaxed about it Attitude to angina -8 to +10 Back at work, attending gym QOL: from 50 to 70% 2017: no admissions, not bypass or stent, off ISMN Win win

20 Chesterfield AMP results are similar to NRAC (unpublished) Referrals come from hospital & GPs (ratio 2:1) 2: 1 males: female Average age mid 60s (range years) True refractory angina + people with a revasc option First 11 cohorts (n=146) 146 started Data for months 15% did not complete 12 mo f/u 22 slots wasted through DNAs

21 Chesterfield AMP QOL & symptoms 98% reported symptoms of angina had improved 90% reported improved QOL on average by 22% 35% reduction in misconceptions score Patient satisfaction with the programme very high best bit was all the information it has taken away the worry I can cope now I understand what is happening I wish I had had this 10 years ago things would have been so different

22 Chesterfield AMP savings 59 had a possible palliative revascularisation option After 12 months 22 of 29 (77%) did not go on to PCI 27 of 30 (90%) did not go on to CABG/re-do CABG Overall reduced hospital activity compared to 12 mo before recruitment with overall savings of 800 pp

23 Self Management Interventions for Chronic Stable Angina 2014 Meta-analysis of 7 short term RCTs showed 1 Fewer episodes of angina & less use of GTN Improved depression scores Fewer admissions & shorter length of stay Bradford Angina Service: showed improvement in symptoms of depression & QOL 2 Specialist Angina Service Royal Brompton & Harefield improved psychosocial outcomes, QoL & drug use 3 1 McGillion. BMC CV Disorders 2014, 14:14 2 Patel P. Br J Cardiol 2016;23: Cheng BCS 2017 poster

24 NICE 2011 Care pathway

25 Key points Angina is frightening for patients and their families Most patients don t understand their condition People need to know that angina doesn t damage the heart but a sign the heart growing collaterals which will protect it from damage if a heart attack happens in the future Angina Management Programmes which provide education, challenge misconceptions and promote stress management & relaxation to control symptoms empower patients to make healthy lifestyle choices which can reduce the need for investigations, surgery and drugs