Coronary heart disease (CHD) is the single commonest cause of premature death in the United Kingdom (UK). The research evidence relating to the management of CHD is well established and if implemented can reduce the risk of death from CHD and improve the quality of life for patients. This measure is one of ten Secondary Prevention of Coronary Heart Disease (CHD) measures. The "Secondary Prevention of Coronary Heart Disease (CHD)" indicator set focuses on the management of patients with established CHD consistent with clinical priorities in the four nations.
The Quality and Outcomes Framework (QOF) does not specify how the diagnosis of angina is made or confirmed. This will vary from patient to patient, e.g., clinical history, response to medication, results of investigations, hospital letters, etc.
In general, angina is a clinical diagnosis. Patients with suspected angina should have a 12 lead electrocardiogram (ECG) performed. The presence of an abnormal ECG supports a clinical diagnosis of CHD.
An abnormal ECG also identifies a patient at higher risk of suffering new cardiac events in the subsequent year. However, a normal ECG does not exclude coronary artery disease. Refer to the Scottish Intercollegiate Guideline Network (SIGN) guideline, "Management of stable angina" (SIGN Publication No. 96, February 2007) for further information.
As an additional assessment (rarely for diagnosis), patients with newly diagnosed angina should be referred for exercise-testing or myocardial perfusion scanning.
The aim of further investigation is to provide diagnostic and prognostic information and to identify patients who may benefit from further intervention.
Exercise tolerance testing (ETT) has been shown to be of value in assessing prognosis of patients with coronary artery disease. An ETT is also helpful in patients at high risk of CHD, where a positive test can provide useful prognostic information.
Patients should not be referred for an ETT if:
- They are on maximal medical treatment and still have angina symptoms
- The diagnosis of CHD is unlikely (these patients should be referred to a cardiologist)
- They are physically incapable of performing the test
- They have clinical features suggestive of aortic stenosis or cardiomyopathy
- The results of stress testing would not affect management
Refer to the SIGN guideline, 96 (2007) for further information.
Specialist Referral:
An alternative to referral for exercise-testing is referral to a specialist for evaluation. Referral would normally be to a cardiologist, general physician or general practitioner (GP) with a special interest.
