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EDITORIALS: Michael McGillion, Heather Arthur, Paulin Andréll, and Judy Watt-Watson Self management training in refractory angina BMJ 2008; 336: 338-339 [Full text]

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Cognitive behavioural interventions work in chronic refractory angina

Professor Michael R Chester, Professor Bob Lewin, Dept. Health Sciences, University of York, York, UK.   (24 February 2008)

Cognitive behavioural interventions work in chronic refractory angina 24 February 2008
Professor Michael R Chester, Director of the National Refractory Angina Centre Liverpool Hope University, L14 3PE, Professor Bob Lewin, Dept. Health Sciences, University of York, York, UK. Send response to journal: Re: Cognitive behavioural interventions work in chronic refractory angina	McGillion and colleagues make a number of important observations about the current management of chronic refractory angina. They suggest that a brief cognitive behavioural self-management programme, adapted from the Angina Plan might also be useful in refractory angina. This brief, home based cognitive behavioural self-management programme has been shown to significantly reduce symptoms, anxiety and depression and increase activity levels in patients with chronic stable angina.[1] We have used the Angina Plan as part of the educational programme we routinely provide for chronic refractory angina patients at the National Refractory Angina Centre (NRAC) in Liverpool, UK, in-line with the national refractory angina guidelines.[2] In a recently published paper reporting outcomes for series of 271 patients we observed all of the previously demonstrated benefits as well as a rapid and sustained reduction in unscheduled admissions and heart attack rates among the 271 patients included in the study.[3] Only a small proportion of these patients required the more expensive treatments such as spinal cord stimulation and external enhanced counter pulsation that are routinely recommended by many clinicians before self-management has been explored. The role of mistaken ideas about angina in generating symptoms and disability has been demonstrated.[4] Since 1997 all of the major clinical guidelines for both stable and refractory angina have stated that education and demystification should be central to management. The current General Medical Council good medical practice guidelines also emphasise the importance of a therapeutic alliance between clinician and well informed/educated patients. Unfortunately, in our experience, this critically important aspect of good care is not taken seriously and few angina patients are appropriately educated, and almost none are offered the opportunity to take part a in self-management or rehabilitation programme before a trial of palliative intervention.[5] We believe that in consequence many patients with chronic stable angina progress to costly and unnecessary palliative interventions and in some cases go on to develop ‘refractory’ angina due in part to a number of common, misunderstandings about the natural history of the ‘untreated’ condition and of the things that they could do to control their symptoms and tackle the underlying disease. [6,7] References 1. Lewin RJP, Furze G, Robinson J, Griffith K, Wiseman S, Pye M, et al. A randomized controlled trial of a self-management plan for patients with newly diagnosed angina. Br J Gen Pract 2002;52:194-6. 2. www.angina.org 3. Moore RKG, Groves DG, Bridson J D, Grayson AD, Wong H, Leach A, Lewin RJP, Chester MR. A Brief Cognitive-Behavioral Intervention Reduces Hospital Admissions in Refractory Angina Patients J Pain Symptom Manage. 2007 Mar;33(3):310-316 4. Furze G, Lewin RJ, Murberg T, Bull P, Thompson DR. Does it matter what patients think? The relationship between changes in patients' beliefs about angina and their psychological and functional status. J Psychosom Res. 2005 Nov;59(5):323-9. 5.Bridson J, Hammond C, Leach A, Chester MR. Making consent patient centred BMJ 2003;327;1159-1161 6.Ornish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. Am J Cardiol. 1998 Nov 26;82(10B):72T-76T. 7.Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998 Dec 16;280(23):2001-7. Competing interests: None declared