Introduction: Patients with refractory angina have persistence of symptoms despite optimal pharmacological intervention and consideration for revascularisation. It constitutes significant public health burden, affecting in excess of 5% of patients with angina. Symptoms are typified by a maladaptive psychological response to ischaemic chest pain, commonly allied with high levels of anxiety and depression. Focus of management appears to lack a structured pathway of care to specifically address this issue. As a consequence, there is high morbidity in such patients with recurrent hospital admissions and compromise in quality of life. Our hospital has a specialised cardiology service to manage patients with refractory angina (BRAS). Management includes a short psychological intervention, composed of a course of cognitive behavioural therapy (CBT) combined with an education programme. A study into short-term impact has been previously conducted by our group, and demonstrated that intervention improved quality of life and reduced levels of anxiety and depression, without effects on frequency of symptoms. A follow-up study on the same cohort was conducted after a two-year duration, to compare short and long-term outcome measures.
Methods: The intervention was composed of a 1 month course, delivered over 4 sessions with each lasting 2 hours. These were implemented by a Clinical Nurse Specialist and a Clinical Psychologist in partnership. As previously, assessment was performed using well-established and validated questionnaires (SF36 for quality of life, HADS for anxiety/depression, SAQ for angina frequency/GTN spray usage). Non-parametric data was analysed using Wilcoxon signed-rank testing and presented as medians. Statistical significance was defined as by p-values <0.05.
Results: 33 patients were present in the initial study. Three underwent subsequent revascularisation and were therefore excluded from our analysis. Average age was 62 years (SD 12.6), with 25 males and 5 females. SF36 quality of life scores appeared higher (47 vs 44, p=0.023). Levels of anxiety (6 vs 8, p=0.032) and depression (5 vs 8, p=0.048) were improved. No statistically significant change was noted in frequency of angina (4 vs 3, p=0.106) or usage of GTN spray (4 vs 3, p=0.078).
Conclusions: Our initial study suggested that a short course of psychological intervention was effective in improving patients' quality of life and mood. Despite the relatively small sample size, current results indicate that benefits are maintained in the longer term. This is achieved independent of improvements in frequency of angina or usage of GTN spray. We propose larger, multi-centre trials to establish correlations further.