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The development of a nurse-led angina management programme

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Diane Burke, RN, Dip HEdP.

Cardiac Liaison Sister

Angina is a symptom of coronary heart disease (CHD), caused by an imbalance between the myocardium's demand for oxygen and the ability of the coronary arteries to supply it. This is usually the result of a partial obstruction of a coronary artery by atheroma (de Bono, 1999).

Angina is a symptom of coronary heart disease (CHD), caused by an imbalance between the myocardium's demand for oxygen and the ability of the coronary arteries to supply it. This is usually the result of a partial obstruction of a coronary artery by atheroma (de Bono, 1999).

Angina may occur as a result of a number of stressors such as physical exertion, anxiety, dreaming, being outdoors in cold weather, and eating a large meal. Physical or emotional stress activates the sympathetic nervous system, causing vasoconstriction, increased heart rate, increased myocardial contractility and increased blood pressure. Atherosclerotic arteries are unable to supply the increased oxygen required, resulting in ischaemia and hypoxia. Typical angina pain is a crushing, gripping or tight substernal pain that may radiate to the jaw, neck, shoulder, arm and hand, usually on the left side (Klein, 1988).

Angina appears to have a particularly deleterious effect on a person's quality of life (Lewin, 1997; 1999) and those with angina report increased levels of anxiety, depression, insomnia and fatigue, as well as decreased self-esteem and changes in sexual drive (Reigal and Dracup, 1992).

Management of patients with angina
The evidence base for the care and treatment of patients with stable angina is still developing. Searches of Medline (1990 to April 2002), Cinahl (1982 to February 2002), and PsycInfo (1984 to February 2002), using the key words 'angina', 'rehabilitation' and 'cardiac rehabilitation' identified evidence related to the use of medication (Fox et al, 2001; Spertus et al 2001), coronary revascularisation (Brorsson et al, 2001), exercise (Jolliffe et al, 2001; Bundy et al, 1998) and psychosocial interventions (Bundy et al, 1998). Both hospital-based (Fox et al, 2001) and primary care-based (Lewin et al, 2002) programmes have been positively evaluated for their effectiveness in improving patients' anginal symptoms and quality of life, as well as in meeting individuals' lifestyle and risk factor targets.

Historically, cardiac rehabilitation programmes developed in response to the detrimental effects of the prolonged bed rest that patients who had suffered a myocardial infarction (MI) were prescribed. This bed rest was seen to result in physical and psychological debilitation. Early cardiac rehabilitation programmes were exercise based and aimed to get men (MI was seen at that time as a male problem) back to work (Todd and Cay, 1997; Radley et al, 1998). During the 1980s it became clear that the exercise-based nature of most of the programmes in existence did not meet the psychosocial problems associated with CHD, nor did they address the need for patients to change their risky behaviours (such as smoking).

The advent of evidence-based practice has highlighted that other patient groups (such as ethnic minority patients, women, post-cardiac surgery patients, heart failure patients and those who suffered with angina) would also benefit from some form of cardiac rehabilitation (Todd and Cay, 1997). The National Service Framework (NSF) for CHD (DoH, 2000) states: 'People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events.'

To achieve this, models of care should be used to produce a systematic approach to (DoH, 2000):

- Assess and investigate people with anginal symptoms

- Provide and document the delivery of appropriate advice and treatment

- Offer a regular review to people at high risk of developing CHD.

The angina management programme began in 1997 before much of the current evidence was available but in the knowledge that patients with chronic stable angina had been shown to benefit from exercise and health education (Todd and Cay, 1997). Initially, the standards and multidisciplinary input were based on the established cardiac rehabilitation programme offered to patients post-myocardial infarction because there was little evidence for the effectiveness of nurse-led therapeutic approaches to the management of angina.

The pilot angina management programme
The cardiac liaison department at St James's Hospital, Leeds, was awarded an education grant from Merck, Sharp and Dohme, which funded a part-time cardiac liaison sister (CLS) post for two years. A pilot project was set up with the initial aims listed in Box 1.

Full support was sought and obtained for the pilot from the consultant cardiologists working at St James's Hospital. This support and encouragement has continued throughout the pilot and into the full development of the service.

The success of the pilot project resulted in The Leeds Teaching Hospitals NHS Trust (of which St James's Hospital is one part) agreeing to continue funding the part-time CLS post. A bid was put forward to the British Heart Foundation for a second, full-time CLS post and a clerical support worker. This allowed the service to expand three ways:

- It now includes all patients regardless of age

- It allowed for patient follow up and attendance at the risk factor clinic for up to 12 months

- An exercise and health education programme for this client group was established.

The multidisciplinary cardiac liaison team at St James's meets every six months. At each meeting a team member gives a presentation of one facet of their practice and then time is allowed for networking and an exchange of information. These meetings mean that other team members have a degree of involvement in the project, which has helped to overcome the problem of isolation for the CLSs initiating a new service.

Patient management
Patients with angina are identified by the CLSs and visited while inpatients. The inpatient rehabilitation session usually lasts about an hour. The content of the session is summarised in Box 2.

Personal cardiac health records (PCHRs) are issued to patients and contain individualised plans for managing cardiac risk factors. A programme of education has been ongoing in order to promote the multidisciplinary use of the records across primary and secondary care.

Patients are invited to attend the cardiac risk factor clinic at three-, six- and 12-months post-discharge. Each appointment lasts approximately 45 minutes. Patients are weighed and their blood pressure, random total cholesterol and random blood sugar (if appropriate) are recorded. Levels of exercise, smoking and alcohol intake are also assessed. All information is recorded in the patient's medical records and on their PCHR.

A patient's motivation to make lifestyle changes is assessed using the 'Cycle of Change' model (Prochaska and DiClemente, 1983) and goals are set accordingly. Psychological status is assessed at each visit using the Hospital Anxiety and Depression (HAD) scale (Zigmond and Snaith, 1983). Any identified problems are explored and patients are offered referral as appropriate to the psychiatric liaison team or clinical psychologist. A monthly meeting between the CLSs, the psychiatric liaison team and the clinical psychologist allows for discussion and allocation of new referrals and update on the progress of existing clients.

At each clinic appointment cardiac risk factors are reassessed and advice reiterated. New goals and targets are set for meeting lifestyle changes and are written in the PCHR. Patients are encouraged to take their personal health records to all appointments with primary and secondary health-care providers.

Communication with a patient's consultant is facilitated via the clinic report, which is recorded in an individual's medical record. Medical staff are contacted should the CLSs have concerns about an individual during a consultation. Liaison with primary care teams is via a progress report sent to all patients' GPs and practice nurses and through documentation in the patient's PCHR.

In March 2001 an exercise and health education course was started for angina patients. Each course runs twice weekly for four weeks and can accommodate up to 10 patients. Everyone who attends is asked to complete the Cardiovascular Limitations and Systems Profile (CLASP). This profile was developed by Devlen, Michaelson and Maguire in the Department of General Practice at the University of Manchester and is presented in the NSF (DoH, 2000) as a tool that may be used as part of a systematic approach to assessing patients. CLASP is used by the CLSs to assess patients before exercise and detect any deterioration in symptoms during and following completion of the programme.

The health education component of the programme includes relaxation and stress management, information about the benefits of exercise, smoking cessation advice, information about medications and information on a cardioprotective diet. Dietary information comes in two parts, a group discussion and a visit to a local supermarket to identify cardioprotective food options. The CLSs are trained to give smoking cessation advice; however, patients are referred to specialist advisers if necessary. The local heart support group also has input into the programme. Although the exercise and health education course is in its infancy, it is receiving positive feedback from those who attend. An audit of patient satisfaction with the course is currently being planned.

Audit of the angina management programme
The NSF for CHD (DoH, 2000) lists investigations and interventions for people who have stable angina. The therapeutic nature of this programme means that those who attend receive support and advice on reducing their cardiovascular risk. The audit of this programme was set up as an integral part of its delivery initially to report back to the funding bodies. It now also offers evidence that the NSF standard for stable angina, preventing CHD in high-risk patients and cardiac rehabilitation are being addressed.

The service has steadily expanded. During 2001, 504 patients were seen by the two CLSs. Of these, 371 new patients were referred to the cardiac risk factor clinic. In total, 531 new and follow-up patients were sent invitations to attend the clinic. Of these 346 (65%) attended their appointment, 96 (18%) were unable to attend - most were rescheduled. Eighty-nine (17%) did not attend and gave no reason for not attending.

The breakdown of patients attending three-, six- and 12-month clinics in 2000 is shown in Figure 1.

Chest pain - Chest pain has been shown to have a detrimental effect on an individual's quality of life and angina management programmes have been shown to reduce the level of angina experienced as well as levels of anxiety associated with this condition (Lewin, 1999). For those attending this programme levels of angina appeared to be relatively low, with just over half of the 346 patients (53%) attending the risk factor clinic reporting having less than one episode of angina each week (Figure 2). However, as Lewin (1999) notes, people with angina often have exaggerated health worries and, without a programme designed to meet their needs, many people become unnecessarily disabled by their angina. Thus low levels of chest pain may not equate with low levels of anxiety and disability.

Smoking - As the major preventable cause of CHD smoking is particularly targeted in the NSF for CHD. Smoking cessation clinics are seen as an essential part of the secondary prevention of CHD (DoH, 2000; HDA, 2000). The Government's White Paper on tobacco Smoking Kills (DoH, 1998) set targets to reduce smoking in all adults, pregnant women and children. In adults the aim is to reduce smoking from 28% to 24%, leading to around 1.5 million fewer smokers by 2010.

Of the 346 patients attending the clinic during 2000, 60% were non-smokers, 31% still smoked and 8% had given up. The percentage of individuals smoking who have been admitted with chest pain is greater than the national percentage of smokers, which is to be expected given the relationship between smoking and CHD. Although a reduction of 8% appears small it needs to be read in the context of a national reduction of 4%.

Smoking cessation support and advice is given using the 'Stages of Change' model (Prochaska and DiClemente, 1988). Intervention is given dependent on the stage of change the individual has reached:

- Precontemplative: the individual has no desire to stop

- Contemplative: where the individual wants to stop smoking one day

- Planning: where the individual wants to stop in the next four to six weeks

- Action: where the individual has stopped within the last six months

- Maintenance: where the individual stopped some while ago.

Cholesterol, diet and alcohol intake - Advice on diet, cholesterol levels and the use of statins is highlighted in the NSF for CHD (DoH, 2000). Initial cholesterol levels are measured while the patient is an inpatient and thereafter at each clinic visit. If the cholesterol level is found to be over 5mmol/l at the clinic the patient is given cholesterol-lowering dietary advice and advised to see his or her GP to re-check cholesterol levels and either begin taking a statin or increase the dose if he or she is already taking a statin. A pre-printed letter is sent to the GP, supporting this advice.

Figure 3 shows the number of patients attending the clinic in 2000 with cholesterol levels greater than 5mmol and also the number of patients prescribed statins.

Dietary modification may help reduce a patient's total cholesterol by up to 10%. A full dietary assessment is carried out either as an inpatient or at the first clinic appointment. The dietary advice given for a cardioprotective diet includes that listed in Box 3.

Of the 346 patients attending the clinic in 2000, 135 were given dietary goals. Only 13 patients out of the 135 reported failing to meet their dietary goals.

Current weekly benchmarks for alcohol are 21 units for men and 14 units for women. Two alcohol-free days each week are recommended. Regularly drinking over these limits poses a progressive threat to health (Whent et al, 1997). The cardiac risk factor clinic audit showed that 84% of those who attended reported drinking within the guideline limits, while only 11% reporting drinking more than the limits.

Medications - The NSF requires that those with angina be offered medication to reduce their risk of an acute coronary event. This should include (DoH, 2000):

- Low-dose aspirin, unless contraindicated for instance by active peptic ulceration

- Beta-blockers within the first 24 hours after an unstable angina episode then for at least one year afterwards

- ACE I inhibitor (ACE I) if there is evidence of left ventricular failure. However, with the HOPE study results it is likely that ACE I inhibitors will be prescribed for all high-risk CHD patients (Mancini and Stewart, 2001)

- Statin and dietary advice to reduce serum cholesterol either to less than 5mmol/L (LDL-C to below 3mmol/L) or by 30%, whichever is greater.

Treatment for symptom control should include:

- Taking short-acting nitrates

- Additional therapy, if indicated, with oral nitrates and calcium channel antagonists

Of the 346 patients who attended in 2000, 65% were taking a statin, 95% were taking low-dose aspirin, 61% were taking beta-blockers and 37% ACE I inhibitors.

Exercise - A systematic review of randomised trials of secondary prevention programmes in CHD (McAlister et al, 2001) demonstrates that comprehensive disease management programmes have a positive impact on subsequent morbidity and mortality in patients with CHD. Although few of the trials reviewed included structured exercise as part of the intervention, there appeared to be a trend towards greater survival benefit in programmes that included exercise. Exercise-based cardiac rehabilitation has been shown to be effective in reducing cardiac death in younger men who have suffered an MI (Jolliffe et al, 2001). Jolliffe et al concludes that individual cardiac units need to decide whether exercise-based rehabilitation should be extended to other groups such as those with angina. Contraindications to taking part in an exercise programme include unstable angina, unstable heart failure, uncontrolled hypertension or uncontrolled ventricular arrhythmias. The decision was made to include a supervised exercise component so that participants would have the opportunity to take supervised exercise and become confident in their ability to exercise.

Relation of exercise to a sense of well-being - The current guideline for physical activity is to achieve 30 minutes of moderate-intensity activity (such as brisk walking, swimming, cycling) on at least five days of the week (DoH, 1996). Of the patients who attended the cardiac risk factor clinic just over one-third (37%) reported taking more than 30 minutes exercise five times per week. This may reflect the greater age and amount of co-morbidity among the patients seen at the clinic. Future audits will indicate if this percentage increases. Future research aims to evaluate the effectiveness of the exercise component in encouraging the individuals who attend to increase their levels of activity.

Return to work - As CHD is a chronic disease that mainly affects older people it is likely that a significant number of those who attend the cardiac risk factor clinic will be retired. Others may have retired for medical reasons either because of angina or other chronic conditions such as arthritis. Data for the year 2000 showed 260 (75%) patients were not working before their first admission with angina. Of the 72 patients who had been in employment, 46 (64%) had returned to work. Fourteen patients did not have their employment status assessed.

Discussion
Overall the angina management programme appears to have been well received by patients, relatives and medical staff. Anecdotal evidence has shown patients value the input they receive and feel supported by this programme. This anecdotal evidence underpins the value of developing innovative nurse-led cardiac rehabilitation for groups of patients that have not been catered for until recently. It is planned that a formal evaluation of this programme will continue through the use of patient satisfaction questionnaires and clinical audit.

The development of a programme such as this has not been without its complications. There was an initial need to convince others of the benefits of the service, which was overcome by careful audit, and the presentation of findings to all disciplines. The support of the consultant cardiologists was and still is invaluable. Practical difficulties have included sometimes mundane issues such as negotiating office and clinic space. The importance of setting up links with the multidisciplinary team was identified early on in the project.

The popularity of the service has meant that the programme has become a victim of its own success and the increased patient numbers has meant that the clinic visits are routinely offered at three and six months with 12-month appointments for those assessed as needing longer term support. Planned developments for the angina management project are:

- The creation of a seamless pathway for patients with angina with clear communication lines across sites for patients requiring invasive investigations and revascularisation

- Links with primary care nurses to help establish secondary prevention CHD clinics.

- An expansion of the exercise/health education programmes from four to six weeks, in line with the NSF guidelines

- To begin a collaborative, multidisciplinary research programme evaluating the angina management programme, including assessment of quality of life.

People who suffer from angina have a multitude of needs. This programme is beginning to address as many of these needs as is possible using the resources currently available.

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