S Morrison. New Expert Forum Highlights Concerns About Angina Management. The Internet Journal of Cardiology. 2003 Volume 2 Number 2.
A new multidisciplinary group of UK experts in coronary heart disease, the Angina Forum, has placed angina management firmly on the cardiovascular agenda in its inaugural meeting at the Congress of the European Society of Cardiology in Vienna. Chaired by Professor Henry Dargie, Consultant in Cardiology at the Western Infirmary, Glasgow, the Forum was brought together in response to worrying data on angina treatment in the UK. Its objectives are to identify current problems and challenges in angina management, explore ways towards more effective treatment and offer advice and comment to clinicians. The eight-strong group comprises six angina specialists from secondary care, a special interest general practitioner and a CHD pharmacy adviser. According to the Health Survey for England, approximately 4% of adults are afflicted by angina1. Of the total cost to the NHS of around £700 million a year, only around £80 million is spent on medical therapy2. In the light of the considerable advances made in pharmacological treatment for ischaemic heart disease, this underlines the relatively static situation in angina management, with drug therapy largely dependent on older agents. 'Medical treatment for angina has been a forgotten area in many ways', comments Professor Dargie. He adds that clinicians dealing with high levels of mortality often mistakenly believe that angina patients have a good prognosis. 'They may have a good prognosis relative to heart failure, for example, but they still have an incidence of coronary events which is much greater than people without ischaemic heart disease, and I think that's something we shouldn't underestimate,' he stresses.
Research carried out in August this year - specifically to inform the new Forum - showed a high level of dissatisfaction, among both primary and secondary care clinicians, about current therapeutic options in angina management. The research, which included GP focus groups and a face-to-face survey of cardiologists3, showed that more than a quarter of respondents felt that angina management was sub-optimal, while more than 40% agreed that current medical therapy was 'far from ideal'.
This inaugural session of the Angina Forum aimed to consider these data and build a realistic picture of angina management in today's practice. What emerged was a picture of confusion in primary care, compounded by the lack of sound national guidelines.
'The Joint British Guidelines are not intended to tell you much about the management of angina,' comments Dr Henry Purcell, Senior Fellow in Cardiology and Honorary Consultant at the Royal Brompton Hospital, London. 'I don't think there is any definitive, easily accessible document that most of us could go to in the UK.'
He also highlights the problems of undiagnosed angina. ‘‘There may well be many people with stable angina being treated with Gaviscon [an antacid] out there. It's a life threatening disease, so we need to establish whether the patient has ischaemic symptoms,' he says. Dr Hugh McIntyre, Consultant Physician, Conquest Hospital, East Sussex Hospitals Trust and Honorary Consultant Cardiologist at the Brompton Hospital, London, adds: 'The lack of shape and standardisation in the treatment process reflects the lack of clarity and structure in current angina management.'
The group also looked at the strengths and weaknesses of currently available medical therapy, including nitrates, beta blockers and calcium channel blockers. The importance of heart rate reduction, in particular, was stressed. Dr Purcell points out that the European Heart study and other trials show a clear relationship between heart rate and ischaemic events, particularly in those with existing ischaemic heart disease.
While current therapies, such as beta blockers and rate reducing calcium channel blockers achieve this therapeutic goal, there are major drawbacks, according to Professor Jennifer Adgey, Professor of Cardiology at the Royal Victoria Hospital, Belfast.'If people stay on a beta blocker then fine. But compliance is poor.' She points outs that compliance with newer agents has improved, but adds: 'I think we have to find newer agents when we're talking about heart rate, because beta blockers are generally not well tolerated.'
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