Coronary heart disease (CHD) is the most common single cause of adult death, and even before it was subject to a National Service Framework it merited our best endeavours. Angina pectoris is a symptom, not a diagnosis, but implies underlying CHD, and therefore requires serious, timely and appropriate intervention.
The Scottish Intercollegiate Guidelines Network (SIGN) has a reputation for producing good, evidence-based guidelines, and has recently produced a guideline on the management of stable angina.1 This provides thorough recommendations on how to manage patients with angina, with evidence to support them.
Both the recommendations and the evidence are graded to give an accurate idea of how to weight them. This facilitates local implementation, which is dependent on the facilities and services available. Thus the detail will vary from place to place.
The guideline committee already had a very sound guideline to take as an example, i.e. that produced by the North of England Evidence Based Guideline Development Group.2 This was felt to be of such quality that it was taken as the starting point for the new guideline.
The SIGN guideline is eminently usable, being presented as a 26-page soft cover A4 booklet, which goes into detail, but also containing a simple pocket-size folded card with the main, graded recommendations. The guideline is also accessible on the SIGN website (www.sign.ac.uk).
Most of what is in the guideline seems self-evident or logical, but I certainly found it a useful aide-mémoire and gained some helpful new insights and guidance. In addition to the graded recommendations and evidence, there are highlighted 'good practice' points.
The format is logical, starting off with initial history and examination and tests. The simple point is made that patients with angina should have a 12-lead ECG, and those in whom this is abnormal should be considered for urgent referral.
The importance of the exercise tolerance test is emphasised for its value in risk stratification.
The guidelines go on to cover management of the major risk factors: smoking, hypertension, diet, overweight, cholesterol, physical activity and excess alcohol consumption. The advice largely follows that which one would expect, but it is helpful to have it set out together.
Drug treatment is covered, reminding us of the need for every patient with angina to be on aspirin (75mg daily) and on clopidogrel in the event of true aspirin intolerance. Glyceryl trinitrate for short-term relief, and the options for long-term prevention (beta-blockers being the first choice when not contraindicated), are then discussed.
Finally, the guideline covers implementation and audit, with recommendations for further research.
There is always a danger, when treating commonly occurring conditions, of being complacent and continuing to do things the way we have always done, often assuming that to be best practice.
In the current era of rapidly occurring advances in clinical knowledge and techniques, we do need guidelines such as this, and others produced by SIGN, to refer to during or between consultations, to ensure that our practice remains as good as we would like it to be. SIGN is Scottish, but the message is just as valid elsewhere in the UK.
- See also 'SIGN guideline on angina could reduce CHD deaths' in this issue.
- Management of Stable Angina: a national clinical guideline. SIGN Guideline No. 51. Edinburgh: SIGN, April 2001.
- Eccles M et al. North of England Evidence Based Guideline Development Group. Evidence Based Clinical Practice Guideline. The Primary Care Management of Stable Angina. Newcastle upon Tyne, Centre for Health Services Research, Report 98, 1999.