2237The effect of a multi-disciplinary care pathway for refractory angina on psychological outcomes, quality of life and medication use

Abstract

Introduction: Refractory angina (RA) is a growing clinical problem due to improved survival from coronary artery disease (CAD). These "no option" patients experience chronic angina-type pain, in the context of CAD, despite optimal medical and surgical therapies. Consequently, management is difficult and outcomes remain suboptimal. As mortality is no worse in these patients, the focus of treatment has turned to improving psychosocial outcomes and quality of life (QoL), assessed using validated questionnaires e.g. Hospital Anxiety and Depression Scale (HADS) and the Seattle Angina Questionnaire (SAQ). Purpose(s): To assess the impact in our centre of a multi-disciplinary care pathway on psychosocial outcomes, QoL and use of cardiovascular medications. Method(s): We undertook a retrospective search of the Electronic Patient Record/Infoflex database at our centre for all patients with RA seen in the Specialist Angina Service from 23/01/2003 to 06/06/2016. Data collected included pre- and post-intervention HADS and SAQ scores, use of the Angina Plan, pain clinic referral, use of cardiovascular medications and the degree of reversible ischaemia. Data was analysed using Wilcoxon matched-pairs signed rank tests and chi-squared tests. Statistical significance was at p<0.05. Result(s): A total of 190 patients were retrieved. The Angina Plan was used in 80.5% (n=153) and 38.9% (n=74) patients were referred to the pain clinic. Patients with pre- and post-questionnaire scores were identified. Significant improvements were observed in anxiety (p=0.0005), depression (p=0.0469), and QoL including all subsets: physical limitation, frequency and perception of symptoms and treatment satisfaction (all p<0.0001). Nicorandil use was reduced (p<0.05) and significant increases in ivabradine and ranolazine (p<0.0001) were observed. Other anti-anginal and disease modifying drugs were unchanged (p>0.05). Furthermore, 52.8% of patients had no change or a reduction in their medication, of which 44.1% had no ischaemia, 47.1% minor/mild, 8.82% moderate and 0% severe. Conversely, in patients with an increase in medication, there was a significantly greater burden of reversible ischaemia - none: 20.0%; minor/ mild: 50.0%; moderate: 16.7%; severe: 13.3% (p<0.001). Conclusion(s): In this study, we have shown that a multi-disciplinary care pathway for patients with RA significantly improves psychosocial outcomes, QoL and medication use. Furthermore, use of the Angina Plan was high illustrating the benefits of specialist nursing expertise. Medication use was largely reduced or unchanged (except for increases in ivabradine and ranolazine likely due to their introduction to the market) and was associated with a reduced ischaemic burden, suggesting in part a non-cardiac aetiology. In the literature, little is reported about the potential impact of such specialist services in improving outcomes in these challenging patients. Further studies are required to validate this approach.