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11/13/24, 8\:17 PM Guide | Explaining a diagnosis of angina

Explaining a diagnosis of angina

Table of contents

Introduction

Being able to share information in a clear and concise way is an essential skill in all
simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis.
Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may
also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format in order to
communicate more e
This guide provides a step-by-step approach to explaining a diagnosis of angina. You should also read our overview of how to
e

Structuring your explanation

Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information
being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.
BUCES structure for explaining a diagnosis

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before
explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to
establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better
understanding of their problem. After introducing yourself, it is important to take a brief history (this is the
structure)\:
What has brought the patient in to see you today?
What are their symptoms?
Are there any risk factors that can be identi
For example, a patient with angina may describe episodes of chest pain or tightness on exertion.
Tip\: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all
your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction
and brief history between 1-2 minutes maximum.

What does the patient understand?

Following a brief history, it is important to gauge the patient’s knowledge of their condition. Patients may know someone with
the condition, or this may be their
misconceptions they may have. The patient sitting before you may not even know at this point that they have angina – you may
be the
Due to these reasons, it is important to start with open questioning. Good examples include\:
“ W h a t d o y o u t h i n k i s c a u s i n g y o u r s y m p t o m s ?”
“ H a v e y o u h e a r d o f a n g i n a b e f o r e ?”
“ W h a t d o y o u k n o w a b o u t a n g i n a ?”
“ W h a t h a s b e e n e x p l a i n e d t o y o u a b o u t a n g i n a s o f a r ?”
Open questioning should help you to determine what the patient currently understands, allowing you to tailor your
explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks
(i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal
communication such as nodding).
Checking the patient’s understanding should not be solely con
throughout by repeatedly ‘chunking and checking’
.
Tip\: Try using phrases such as\:
“ J u s t t o c h e c k t h a t I a m e x p l a i n i n g a n g i n a c l e a r l y , c a n y o u r e p e a t b a c k t o m e w h a t y o u
u n d e r s t a n d s o f a r ? .
” This is far better than only saying “ W h a t d o y o u u n d e r s t a n d s o f a r ?” as the onus is placed upon the quality
of your explanation rather than there being an issue with the patient’s ability to understand.

What are the patient’s concerns?

The patient’s concerns should never be overlooked. A diagnosis of angina can be a signi
of worries. Asking the patient if they have any concerns before beginning your explanation allows you to speci
is most relevant to the patient, placing them at the centre of the explanation. The “ICE” (ideas, concerns and expectations)
format, can provide a useful structure for exploring this area further.

ICE

Ideas
What does the patient think is causing their symptoms?
What is their understanding of angina?
Concerns
What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations
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What is the patient hoping to get out of the consultation today?

Explanation

After determining the patient’s current level of understanding and concerns, you should be able to explain their condition
clearly. Avoid medical jargon so as not to confuse your patient.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect.
" I’ m g o i n g t o b e g i n b y t a l k i n g a b o u t h o w t h e h e a r t w o r k s a n d t h e n m o v e o n t o d i s c u s s w h a t a n gi n a i s , w h a t c a u s e s i t a n d h o w
w e c a n m a n a g e i t t o g e t h e r .
"
In preparation for your OSCE, practice your explanation in patient-friendly terms. Consider using visual aids such as diagrams
or drawings to help understanding.
Tip\: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.

Normal anatomy/physiology

“ T h e h e a r t i s a m u s c u l a r o r g a n i n t h e c e n t r e o f y o u r c h e s t t h a t a c t s a s a p u m p , d e l i v e r o x y g e n a n d n u t r i e n t s t o y o u r o r g a n s a n d t i s s u e s .
"
c i r c u l a t i n g b l o o d t h r o u gh o u t y o u r b o d y t o
“ T h e h e a r t r e q u i r e s i t s o w n b l o o d s u p p l y . T h e a r t e r i e s w h i c h s u p p l y t h e h e a r t a r e c a l l e d t h e c o r o n a r y a r t e r i e s .
”
1

What is angina?

Angina is pain, tightness, heaviness or constricting discomfort caused by reduced blood
muscle). Explain to the patient that it typically presents in the chest, however, it can also radiate to the neck, shoulders, jaw or
arms.
The patient should understand that angina often occurs when the heart works harder than usual (on exertion), such as during
exercise.
Additionally, explain that there are two types of angina\:
2-4
Stable angina has a predictable pattern, usually occurring during physical exertion and is relieved within minutes by rest or
glyceryl trinitrate (GTN) spray.
Unstable angina is more serious and unpredictable. It is considered a type of acute coronary syndrome, and immediate
referral to hospital is necessary.
" A n g i n a i s c h e s t p a i n o r d i s c o m f o r t t h a t h a p p e n s w h e n y o u r h e a r t i s n' t ge t t i n g e n o u gh b l o o d , o f t e n b e c a u s e o f n a r r o w e d
a r t e r i e s . I t c a n b e t r i g g e r e d b y p h y s i c a l a c t i v i t y , s t r e s s , o r c o l d w e a t h e r .
"
" T h e r e a r e t w o t y p e s \: s t a b l e a n d u n s t a b l e . S t a b l e a n g i n a t y p i c a l l y o c c u r s d u r i n g e x e r c i s e a n d go e s a w a y w i t h r e s t o r
m e d i c a t i o n . U n s t a b l e a n g i n a i s m o r e s e r i o u s a n d p o s e s a g r e a t e r r i s k . I t c a n h a p p e n a t r e s t , b e m o r e i n t e n s e a n d m a y n o t
i m p r o v e w i t h m e d i c a t i o n .
"

What are the causes of angina?

Angina is typically caused by coronary artery disease, where a build-up of atherosclerotic plaques narrow the coronary
arteries. Less commonly, angina can be caused by coronary artery spasm, valvular disease, or hypertrophic obstructive
cardiomyopathies.
2-3, 5-6
" T h e m o s t c o m m o n c a u s e o f a n g i n a i s c o r o n a r y a r t e r y d i s e a s e , w h e r e t h e a r t e r i e s t h a t s u p p l y b l o o d t o y o u r h e a r t b e c o m e
n a r r o w e d d u e t o a b u i l d-u p o f f a t t y d e p o s i t s . T h i s c a n h a p p e n d u e t o f a c t o r s l i k e a n u n h e a l t h y d i e t , l a c k o f e x e r c i s e , s m o k i n g,
a g e i n g , o r a f a m i l y h i s t o r y o f h e a r t d i s e a s e .
"

Problems/complications of angina

Explaining the potential complications of angina is necessary so that the patient can recognise problems early and take
appropriate action. This information needs to be delivered in a sensitive manner. Awareness of common problems will
encourage patients to adhere to their treatment and remain vigilant for red
attention.
2
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It is important not to scare the patient, but to explain that you are outlining the potential risks so that they are aware of them.
Risks and the necessary modi
complications, explain that you and the patient will work together to reduce the likelihood that they will occur.
Myocardial infarction
“ I f t h e f a t t y d e p o s i t s b u i l d u p s o m u c h t h a t t h e a r t e r y w h i c h s u p p l i e s t h e h e a r t m u s c l e b e c o m e s c o m p l e t e l y b l o c k e d , c a l l e d a h e a r t a t t a c k . T h i s c a n c a u s e p e r m a n e n t d a m a ge t o t h e h e a r t a n d i t s f u n c t i o n .
”
t h i s i s
Stroke
“ F a t t y d e p o s i t s c a n a l s o b u i l d u p i n o t h e r b l o o d v e s s e l s t h r o u g h o u t y o u r b o d y , i n c l u d i n g t h o s e t h a t s u p p l y y o u r b r a i n . v e s s e l s b e c o m e b l o c k e d , i t c a n c u t o
”
I f t h e s e
Unstable angina
“ I f y o u t h i n k y o u r a n g i n a i s l a s t i n g l o n ge r t h a n n o r m a l , s h o u l d a t t e n d h o s p i t a l i m m e d i a t e l y .
"
i s o c c u r r i n g a t r e s t o r i s m o r e s e v e r e , i t i s a m e d i c a l e m e r ge n c y , a n d y o u
Sudden cardiac death
“ I n r a r e c a s e s , a n g i n a c a n l e a d t o s u d d e n d e a t h .
”
Reduced quality of life
“ W e u n d e r s t a n d t h a t a n g i n a c a n l i m i t y o u r a b i l i t y t o e n g a g e i n y o u r u s u a l a c t i v i t i e s , p a r t i c u l a r l y t h o s e r e q u i r i n g p h y s i c a l a c t i v i t y .
T h i s c a n b e c h a l l e n g i n g , a n d w e r e c o g n i s e t h a t l i v i n g w i t h a n g i n a c a n b e b o t h s t r e s s f u l a n d c o n c e r n i n g. P l e a s e k n o w t h a t w e
a r e a l w a y s h e r e t o s u p p o r t y o u a n d a d d r e s s y o u r w o r r i e s .
”
Further support
“ T h e r e a r e m a n y w e b s i t e s t h a t c a n p r o v i d e m o r e i n f o r m a t i o n o n a n g i n a a n d p r o v i d e m o r e s u p p o r t . H e a r t F o u n d a t i o n .
”
O n e e x a m p l e i s t h e B r i t i s h

Management

With the right lifestyle changes and medical treatment, more than half of people with angina can expect to be symptom-free
within a year.
2
“ O u r g o a l i n t r e a t i n g y o u r a n g i n a i s t o r e d u c e h o w o f t e n y o u h a v e s y m p t o m s , m a k e t h e m l e s s p a i n f u l , a n d r e l i e v e d i s c o m f o r t
q u i c k l y . W e a l s o w a n t t o p r e v e n t y o u r c o n d i t i o n f r o m w o r s e n i n g a n d l o w e r y o u r r i s k o f h a v i n g a h e a r t a t t a c k o r s t r o k e i n t h e
f u t u r e .
”
Explain to the patient that there are steps they can take in their own lives and things you will do as their doctor.
“ W e r e c o m m e n d a c o m b i n a t i o n o f h e a l t h y l i f e s t y l e c h a n ge s a n d l o n g-t e r m m e d i c a t i o n s . I c a n e x p l a i n a n d d i s c u s s t h e s e
o p t i o n s w i t h y o u i n m o r e d e t a i l s o y o u h a v e a c l e a r e r u n d e r s t a n d i n g o f h o w t h e y w i l l h e l p . I t m a y t a k e s o m e t i m e t o
w h a t w o r k s f o r y o u , a n d w e w i l l w o r k t o g e t h e r t o o p t i m i s e y o u r t r e a t m e n t , t o a l l o w y o u t o l i v e y o u r l i f e a s n o r m a l l y a s p o s s i b l e .
”
Non-pharmacological
All patients with angina should be encouraged to adopt several lifestyle changes.
“I n a d d i t i o n t o t h e m e d i c a t i o n , y o u c a n c h o o s e t o m a k e s o m e l i f e s t y l e c h a n g e s t h a t c o u l d r e d u c e y o u r r i s k o f h e a r t a t t a c k s a n d
c a n h e l p p r e v e n t y o u r a n g i n a f r o m w o r s e n i n g .
”
Start by explaining what the patient can do to manage their condition, including\:
7
Smoking cessation advice (if relevant)
Weight loss if the patient is overweight or obese
Physical exercise to help improve cardiac function and collateral blood supply
Eating a ‘cardioprotective’ diet low in saturated fats, transaturated fats and cholesterol. Encourage fruits, vegetables, whole
grains, nuts, and oily
Limiting alcohol consumption, as excess alcohol can increase blood pressure and weight gain. Advise patients to keep
within the recommended 14 units per week.
Pharmacological
Pharmacological treatments can be divided into immediate and long-term.

Immediate

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Sublingual GTN is available as a tablet or spray to quickly relieve angina symptoms. It can also be used preventively before
activities that typically trigger angina. It works by dilating blood vessels and increasing blood supply to the myocardium.
2
“ W e c a n g i v e y o u a m e d i c a t i o n c a l l e d G T N s p r a y t o u s e w h e n y o u h a v e a n gi n a . I t s h o u l d p r o v i d e q u i c k r e l i e f f r o m y o u r p a i n o r
d i s c o m f o r t . I f y o u k n o w y o u a r e g o i n g t o d o s o m e t h i n g t h a t m i g h t t r i g ge r y o u r a n gi n a , y o u c a n u s e t h e s p r a y b e f o r e h a n d . T h i s
w a y , y o u c a n c a r r y o n w i t h y o u r a c t i v i t i e s m o r e c o m f o r t a b l y .
”
Explain what to do if the patient experiences symptoms of atypical or unstable angina.
“ I f y o u e x p e r i e n c e c h e s t p a i n , y o u s h o u l d s t o p w h a t y o u a r e d o i n g , r e s t a n d u s e y o u r G T N s p r a y . I f t h e p a i n h a s n o t g o n e a f t e r

c a l l 9 9 9 f o r a n a m b u l a n c e i m m e d i a t e l y .
”

Long-term

Beta-blockers or calcium channel blockers are the
2-3
The choice of drug should be guided by the individual's comorbidities, contraindications, and personal preferences.
“ Y o u c a n t a k e l o n g-t e r m m e d i c a t i o n s d a i l y t o h e l p r e d u c e h o w o f t e n y o u h a v e a n gi n a e p i s o d e s . T h e s e m e d i c a t i o n s c a n a l s o
h e l p t o i m p r o v e y o u r o v e r a l l h e a r t f u n c t i o n . 8
I f y o u a r e s t i l l e x p e r i e n c i n g a n g i n a e p i s o d e s , y o u c a n u s e y o u r G T N s p r a y a s
n o r m a l .
”

Secondary prevention

To prevent the progression of coronary artery disease and lower the risk of future heart attacks and strokes, the following other
medications can be used\:
2
Antiplatelets i.e. aspirin 75 mg daily
ACE inhibitors in those with stable angina and diabetes
Statins
Antihypertensives, if hypertension is uncontrolled
Antidiabetics (if relevant)
“ W e m a y a l s o c o n s i d e r g i v i n g y o u s o m e o t h e r m e d i c a t i o n s t o h e l p p r e v e n t h e a r t a t t a c k s a n d s t r o k e s i n t h e l o n g-t e r m .
”
Surgery
Depending on the symptoms and the response to medical treatment, further investigation may be necessary. Invasive
treatments such as coronary stent procedures or bypass surgery may be o
3
“ I f m e d i c a t i o n s a r e n’ t s u i t a b l e o r d o n’ t w o r k w e l l f o r y o u , w e m i gh t s u g ge s t a n o p e r a t i o n t o i m p r o v e b l o o d
m u s c l e s .
”

Closing the consultation

Summarise the key points back to the patient.
“ W e h a v e d i s c u s s e d q u i t e a l o t t o d a y , i n c l u d i n g w h a t a n gi n a i s , t h e s y m p t o m s y o u m i gh t e x p e r i e n c e a n d h o w t h e c o n d i t i o n i s
m a n a g e d . I r e a l i s e t h i s i s a l o t o f i n f o r m a t i o n t o t a k e i n , s o I h a v e a l e a
i m p o r t a n t t h a t y o u s e e k a r e v i e w i f y o u n o t i c e y o u r s y m p t o m s w o r s e n i n g. I f y o u r a n gi n a e p i s o d e i s n o t i m p r o v i n g d e s p i t e u s i n g
y o u r m e d i c a t i o n s , y o u s h o u l d c a l l a n a m b u l a n c e .
”
Ask the patient if they have any questions or concerns that have not been addressed.
“ I s t h e r e a n y t h i n g I h a v e e x p l a i n e d t h a t y o u’ d l i k e m e t o go o v e r a g a i n ?”
“ D o y o u h a v e a n y o t h e r q u e s t i o n s b e f o r e w e
O
gather more information (examples include Patient.info and NHS Choices).
Thank the patient for their time.
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Dispose of PPE appropriately and wash your hands.

References

1. Patient.info. A n a t o m y o f t h e h e a r t a n d b l o o d v e s s e l s . 2018. Available from\: [LINK].
2. NICE CKS. A n g i n a . 2023. Available from [LINK].
3. NHS.uk. A n g i n a . 2021. Available from\: [LINK].
4. Hermiz C, Sedhai YR. A n g i n a . 2023. Treasure Island (FL)\: StatPearls Publishing. Available from\: [LINK].
5. Patient.info. A n g i n a . 2023. Available from\: [LINK].
6. BHF.org.uk. A n g i n a – C a u s e s , s y m p t o m s & t r e a t m e n t s . 2022. Available from [LINK].
7. NICE CKS. M I - s e c o n d a r y p r e v e n t i o n . 2024. Available from\: [LINK].
8. Santucci A, Riccini C, Cavallini C. T r e a t m e n t o f s t a b l e i s c h a e m i c h e a r t d i s e a s e \: t h e o l d a n d t h e n e w . 2020. Eur Heart J Suppl.
Available from\: [LINK].

Reviewer

Dr Ali Ghanbasha
Specialist in Cardiology
Source\: geekymedics.com
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