Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Diagnosis and Assessment
Establishing a Diagnosis
C - Patients with suspected angina should usually be investigated by a baseline electrocardiogram and an exercise tolerance test.
B - Patients unable to undergo exercise tolerance testing or who have pre-existing electrocardiogram abnormalities should be considered for myocardial perfusion scintigraphy.
Models of Care
B - Following initial assessment in primary care, patients with suspected angina should, wherever possible, have the diagnosis confirmed and the severity of the underlying coronary heart disease assessed in the chest pain evaluation service which offers the earliest appointment, regardless of model.
Pharmacological Management
Drug Monotherapy to Alleviate Angina Symptoms
A - Beta blockers should be used as first line therapy for the relief of symptoms of stable angina.
B - Patients with Prinzmetal (vasospastic) angina should be treated with a dihydropyridine derivative calcium channel blocker.
A - Sublingual glyceryl trinitrate tablets or spray should be used for the immediate relief of angina and before performing activities that are known to bring on angina.
A - Patients who are intolerant of beta-blockers should be treated with either rate-limiting calcium channel blockers, long-acting nitrates or nicorandil.
Combination Therapy to Alleviate Angina Symptoms
A - When adequate control of anginal symptoms is not achieved with beta-blockade a calcium channel blocker should be added.
Drug Interventions to Prevent New Vascular Events
A - All patients with stable angina due to atherosclerotic disease should receive long term standard aspirin and statin therapy.
A - All patients with stable angina should be considered for treatment with angiotensin-converting (ACE) enzyme inhibitors.
Interventional Cardiology and Cardiac Surgery
Choice of Revascularisation Technique
A - Patients who have been assessed and are anticipated to receive symptomatic relief from revascularisation should be offered either coronary artery bypass grafting or percutaneous coronary interventions.
A - Patients with significant left main stem disease should undergo coronary artery bypass grafting.
A - Patients with triple vessel disease should be considered for coronary artery bypass grafting to improve prognosis, but where unsuitable be offered percutaneous coronary intervention.
A - Patients with single or double vessel disease, where optimal medical therapy fails to control angina symptoms, should be offered percutaneous coronary intervention or where unsuitable, considered for coronary artery bypass grafting.
D - Patients undergoing surgical revascularisation of the left anterior descending coronary artery should receive an internal mammary artery graft, where feasible.
Effect of On-/Off-Pump Coronary Artery Bypass Grafting on Cognitive Impairment
A - Off-pump coronary artery bypass grafting should not be used as the basis of providing long term protection against cognitive decline.
Managing Refractory Angina
D - Patients with refractory angina may benefit from an educational and rehabilitation approach based on cognitive behaviour principles prior to considering other invasive treatments.
Stable Angina and Non-Cardiac Surgery
Assessment Prior to Surgery
B - As part of the routine assessment of fitness for non-cardiac surgery, a risk assessment tool should be used to quantify the risk of serious cardiac events in patients with coronary heart disease.
B - Patients undergoing high risk surgery who have a history of coronary heart disease, stroke, diabetes, heart failure or renal dysfunction should have further investigation by either exercise tolerance testing or other non-invasive testing or coronary angiography, if appropriate.
D - An objective assessment of functional capacity should be made as part of the preoperative assessment of all patients with coronary heart disease before major surgery.
Preoperative Revascularisation
D - Coronary artery bypass grafting is not recommended before major or intermediate risk non-cardiac surgery unless cardiac symptoms are unstable and/or coronary artery bypass grafting would be justified on the basis of long term outcome.
D - If emergency or urgent non-cardiac surgery is required after percutaneous coronary intervention, dual antiplatelet therapy should be continued whenever possible. If the bleeding risk is unacceptable and antiplatelet therapy is withdrawn, it should be reintroduced as soon as possible after surgery.
Drug Therapy in Angina Patients Undergoing Non-Cardiac Surgery
A - Preoperative beta-blocker therapy should be considered in patients with coronary heart disease undergoing high or intermediate risk non-cardiac surgery who are at high risk of cardiac events.
B - Pre-existing beta-blocker therapy should be continued in the perioperative period.
C - Low-dose aspirin therapy should only be withheld before non-cardiac surgery in patients with coronary heart disease where the aspirin related bleeding complications are expected to be significant (venous thromboembolism [VTE], myocardial infarction [MI], stroke, peripheral vascular occlusion, or cardiovascular death).
D - If low-dose aspirin therapy is withdrawn before non-cardiac surgery in patients with coronary heart disease, it should be recommenced as soon as possible after surgery.
B - Patients with coronary heart disease undergoing major non-cardiac vascular surgery should be established on a statin before surgery.
Psychological and Cognitive Issues
How Does Angina Affect Quality of Life?
D - Patients with angina should be assessed for the impact of angina on mood, quality of life and function, to monitor progress and inform treatment decisions.
Improving Symptom Control with Behavioural Interventions
B - Patients with stable angina whose symptoms remain uncontrolled or who are experiencing reduced physical functioning despite optimal medical therapy should be considered for the Angina Plan.
The Effect of Treatment for Angina on Cognition
B - Patients undergoing coronary artery bypass grafting should be advised that cognitive decline is relatively common in the first two months after surgery.
D - Patients who are older and have other evidence of atherosclerosis and/or existing cognitive impairment may be more at risk of increasing decline and these factors should be considered when evaluating options for revascularisation to achieve symptom relief.
The Effect of Psychological Factors on Clinical Outcomes Including Mortality
D - Patients undergoing coronary artery bypass grafting should receive screening for anxiety and depression pre-surgery and during the following year as part of postsurgical assessment, rehabilitation and coronary heart disease secondary prevention clinics. Where required patients should receive appropriate treatment (psychological therapy, rehabilitation, medication).
D - Rehabilitation programmes should be implemented after revascularisation for patients with stable angina.
The Effect of Health Beliefs on Symptoms and Functional Status
D - Patients' beliefs about angina should be assessed when discussing management of risk factors and how to cope with symptoms.
B - Interventions based on psychological principles designed to alter beliefs about heart disease and angina, such as the Angina Plan, should be considered.
Patient Issues and Follow Up
Cardiac Waiting Times
C - Early access to angiography and coronary artery bypass surgery may reduce the risk of adverse cardiac events and impaired quality of life.
Follow Up in Patients with Angina
A - Patients presenting with angina and with a diagnosis of coronary heart disease should receive long term structured follow up in primary care.
Definitions:
Grades of Recommendations
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies, e.g., case reports, case series
4: Expert opinion
