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Furze G, Conway B, Rodaway M, Rumsby J. The Angina Plan and the Angioplasty Plan. BACR Newsletter 2004;4(3):7-9
The Angina Plan and the Angioplasty Plan. Angina affects around 2 million people in the UK, and its prevalence is growing as more people survive acute coronary events.1 Over half of these people have symptoms that restrict daily life, and would benefit from knowing how to manage their condition. There is growing evidence that what people believe about their illness can have profound effects on their experience.2-4 Erroneous health beliefs and the resulting mistaken coping strategies adopted by some patients contribute to the disability that they report.5 When people are first diagnosed with angina they often very unsure of what to do. Many of them believe that the bouts of angina are actually small heart attacks. Most of them believe that they must avoid anything that MIGHT bring on a bout of angina. These lead some patients to adopt unhelpful responses, such as undue rest and withdrawing from a 'normal' life,5 which leads to an increasing invalidism, anxiety and depression. Cognitive behavioural treatments target unhelpful beliefs (cardiac misconceptions) as well as helping to prevent maladaptive coping. The Angina Plan Programme The Angina Plan, which was developed with an educational grant from Pfizer Ltd, is a brief, cognitive-behavioural programme. It comprises a 76-page patient-held workbook, a tape or CD based relaxation programme, an advice tape to introduce the concepts in the Angina Plan to the patient before they see the facilitator, and a misconceptions questionnaire. The patient workbook contains information about risk factor reduction, stress management, angina management and how to use goal setting and pacing to increase activity safely. The Angina Plan is introduced to the patient (and their partner) in an interview lasting thirty or forty minutes, and followed up by four, ten to fifteen minute appointments or phone calls over three months. Facilitators are usually health professionals, and the training is by distance learning. People who are not health professionals who wish to become Angina Plan facilitators (for example: fitness instructors or physical activity coordinators) must be legally and medically backed by an NHS trust. The Angina Plan Study.6 We recruited 142 patients with recently diagnosed chronic stable angina from 20 GP practices. The patients were randomised to receive either the Angina Plan or a nurse-led educational session. The educational session patients had their risk factors evaluated and were encouraged to change them, reinforced with written materials from authoritative sources such as the British Heart Foundation. There were no significant differences in any baseline measures. At six month follow-up the Angina Plan patients showed a 43% reduction in episodes of angina (three fewer per week compared to 0.4 fewer per week in the educational session patients, p<0.02). They also showed a significantly greater reduction in; GTN usage ( p<0.02), anxiety (p=0.05), depression (p=0.01) and physical limitations (p<0.001). The Angina Plan Project Although the Angina Plan was developed mainly for use in primary care, its release coincided with an increase in the availability of rapid access chest pain clinics (RACPC) as a consequence of the NSF. As RACPCs were set up, health professionals explored different ways of incorporating the Angina Plan into their care pathways, as the following examples show. Barbara Conway: The Darlington Model. A community cardiac rehabilitation service for people with angina was launched in Darlington in October 2001. This was a programme based in a local leisure centre, run by myself (Specialist Nurse for CHD Rehabilitation) and a Physical Activity Coordinator. The programme is for patients who have angina and have been referred through the rapid access chest pain clinic or GP/Practice nurse. Prior to the introduction of the Angina Plan patients who were unable to attend the rehabilitation programme at the Leisure Complex were given very little support. From February 2002 the Angina Plan was offered to home-based rehabilitation patients. The Physical Activity Co-ordinator and I facilitated it in partnership with the patients and their carers. In March 2002 we extended the service to patients on the group programme with great success. This enabled the Angina Plan to be used in a consistent way with all patients. The topic discussion is based around the workbook and the relaxation tape supports the techniques learnt at the programme. By July 2003 nearly 300 patients had been included in the programme. Patients report greater knowledge of their conditions, reduced levels of stress, fewer angina attacks, reduced isolation and lower cholesterol and blood pressure levels. Twenty-one practice nurses in Darlington have completed or are working towards their Angina Plan facilitation training. They will support the current facilitators by using the Plan as a model of care for patients with angina in Darlington. Using the Plan in an innovative way has been effective in Darlington. All patients leaving the RACPC are offered a rehabilitation service using the Angina Plan. Patients from other hospital clinics with a diagnosis of angina and clinics within general practice can all feed into the service. This work supports the practice nurse led clinics where patients with CHD are reviewed at least annually. This scheme was placed in the top three in the Department of Health national Health and Social Care Awards 2003. Margaret Rodaway: The Devon Experience The population served by South Devon Healthcare NHS Trust covers 3 Primary Care Trust's (PCT's). One PCT has purchased copies of the Angina Plan. My experiences to date of using the Angina Plan with patients have far exceeded expectations of patient benefit. Providing a comprehensive individualised programme, which targets those within secondary care diagnosed with angina, ensures a seamless return to primary care under the care of their GP/Practice Nurse. Patients are identified in secondary care following angiography where medical management is the optimum course of treatment. While Cardiac Rehabilitation (CR) is provided to those post myocardial infarction and cardiac surgery, at present there is no provision for patients with a diagnosis of angina. The Angina Plan is able to address the CR needs of this cohort. I have chosen those patients who have symptoms of stable angina i.e. exertional chest pain relieved with the use of GTN or those on optimum therapy but with reduced activity levels. The satisfaction of guiding each patient as they make positive adjustments to their lifestyle which results in them regaining improved quality of life is both challenging and rewarding. The problems encountered are minimal on reflection of the successes achieved. The Advice and Relaxation cassette tapes have posed a problem, as many people now only have CD players. I have found that angina symptoms are virtually diminished in all patients as they progress through the Angina Plan. Family members have been sceptical about how the programme can alter their relative's quality of life and are surprised at the positive results. Many patients set small goals initially, but soon regain confidence and achieve a lot more through knowledge gained and self-determination. Once patients are successful in one aspect of their CHD risk factor reduction I feel the rest follows as a natural progression to their self-management. All are surprised when angina misconceptions are addressed. It is these that truly hold the patient back in achieving optimum quality of life. Relaxation skills are another hurdle many patients are reluctant to develop, but when confidence is gained everything appears to slot into place. Phase 4 cardiac rehab, healthy walking schemes and exercise on referral are all a natural development for this group. Addressing modifiable CHD risk factors reinforces that lifestyle change is for a lifetime. Jenny Rumsby: The Angina Plan in the Cardiology Day Ward Patients on the Cardiology day ward receive the results of their angiograms before discharge, and it was apparent that these patients could benefit from further information relating to their CHD and support in how to manage their condition and improve overall fitness. Although the Angina Plan met these needs, the pilot studies were carried out in primary care environments, so implementation within a secondary care setting was both innovative and challenging. As the staff were looking at a different way of implementing care it was vital that we supported each other whilst we gained confidence. Patients were offered the Angina Plan once they were out of bed, and interviewed before discharge if they accepted. Subsequent follow up phone calls were then made at the patients convenience. We informed the patients GPs if the patient took up the Plan, to raise awareness, and the practice nurse when it was completed, so the patient would be included in annual CHD clinics. Because our patients come from a very large catchment area (being a tertiary centre), it would have been impractical to try and take on every suitable patient. Therefore we referred patients back to their District General hospitals to be followed up by Angina Plan facilitators from these areas. This was very successful in providing a more equitable service, but also enabled us to form networking links with other professionals. Patients that completed the Angina Plan through the Cardiology Day Ward, were sent a Likert style questionnaire to evaluate its effectiveness. We had very positive responses from the patients with some encouraging feedback, particularly from those patients who were waiting for CABG surgery, and considered the implementation a success. As a result I developed a facilitators support group for clinical supervision and to share best practice, and worked with our IT department to build a data base to store and track patients on the Angina Plan. For me this was a steep learning curve, but I haven't looked back since. My knowledge base has increased, and I now feel more confident in identifying new ways of developing patient care. Gill Furze: The Angioplasty Plan We were asked if the Angina Plan could support people on revascularisation waiting lists. This was fine, but it meant that those people who did not have angina would be at a disadvantage. With support from Hull and East Riding CHD Collaborative we developed the Angioplasty Plan, based on the Angina Plan, but suitable for people with any of the coronary heart diseases. The Angioplasty Plan can be used while people wait, but it also picks up again after PCI. As the patient will have been taught to set goals and pace them, the facilitator can reset goals and keep contact by telephone. This is important for patients who return to work quickly post PCI who may not be able (or willing) to attend hospital based rehabilitation. The Angioplasty Plan can be facilitated with no further training by people who are Angina Plan facilitators. We do suggest that those who are not based in a centre where PCI takes place should forge links with that centre and be conversant with the full patient pathway. New projects As an extension of using the Angina Plan in the community, we are in the early stages of working with a PCT to develop and test having lay-led Angina Plan facilitators, working to a protocol under the supervision of a Cardiac Rehabilitation Team. A "preparation for bypass surgery programme" has recently been developed with grant funding from the British Heart Foundation, this is being tested in a randomised controlled trial, and will not be available (if it proves to be a success) until 2006.
For further information about the Angina Plan: References
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