What's next in angina treatment?

What’s most exciting in angina research right now?

Angina is a symptom experienced when the blood vessels that supply the heart, the coronary arteries, narrow and not enough blood gets to the heart muscle. Most people have a type called stable angina where the narrowing of arteries happens slowly over time.

Doctors previously focused on opening the arteries of people with stable angina in order to prevent heart attacks from happening.

Now we are placing more emphasis on people’s symptoms.

As a doctor and researcher, it’s rewarding to help people get back to what they enjoy.

When you speak to people with angina, over a third will tell you it seriously affects their quality of life.

Because of the chest pain and breathlessness they experience with angina, they are no longer able to pick up their grandchildren, or run for the bus, for example.

Giving people with angina the right medication or procedure lets them get back to what they enjoy.

I’ve had patients tell me they’ve been able to get back to playing in a band because they can now lift their double bass, or even that they completed the National Three Peaks Climbing Challenge after having the right treatment. As a doctor and researcher, that’s very rewarding.

How will research change the way angina is treated?

I think the biggest difference is that in 20- or 30-years’ time treatment will be more personalised.

At the moment, treatment for stable angina tends to be one-size-fits-all, with most people put on the same pathway.

Clinical guidance tells us to try medicines first. Then, if that does not work, they are offered a procedure called angioplasty and stenting, where a small tube called a stent is used to reopen the arteries.

But through trials I’ve conducted, called ORBITA and ORBITA-2, it seems some people would benefit from being offered a stent first.

This is particularly true of those who experience pain in the middle of the chest when they exert themselves, which goes away when they rest.

I’d like to get to the point where the number of people still living with angina symptoms disappears.

We’ve also learned that not everyone feels better with stenting. Somewhere between 30 to 60 per cent of people still feel symptoms after having a successful procedure.

So BHF is now funding my work to find out how we can target stenting to the people who will experience the most benefit.

I am looking at the symptoms people experience, what imaging technology tells us about the narrowing of their arteries, how these and other factors are connected, and how they could be used to predict who stenting will help.

I’d like to get to the point where the number of people who are still living with angina symptoms, despite having multiple different treatments, is far smaller, and maybe even disappears.

Why is it important for BHF to fund research like this?

This is not the kind of research that the medical industry would fund. This is because my research has found that expensive treatments are not always as useful as we might think.

Also, it might not happen in other countries, where clinical research is not so closely linked to the healthcare system, as it is in the UK. Independent charities like BHF recognise the importance of research that investigates questions that matter to patients.

Thanks to BHF funding, science like this has the potential to shape best practice across the world.

What happens if anti-anginal medicines and stenting fail?

Some people with coronary heart disease have treatment, including medicines, stenting or a coronary artery bypass, to open their arteries but they still experience chest pain. We call this refractory angina. It can really affect people’s lives as they have no other options for treatment.

In one of our trials, ORBITA COSMIC, we tested the use of a new device called a coronary sinus reducer.

In regular stenting a stent is used to widen the narrowed artery supplying the heart. By contrast, the hourglass-shaped coronary sinus reducer is used to narrow the heart muscle’s main vein.

This helps blood flow to areas of the heart muscle not getting enough blood. Research may help this to become a regular treatment option in the future.

Microvascular angina is another growing area for research. Most medicines have been developed to treat narrowing in the main arteries that supply the heart. They do not target the problems in the very smallest of arteries which happen with microvascular angina.

Now there are trials taking place, including one funded by BHF, to test out the coronary sinus reducer in people with microvascular angina.

Other researchers are using new imaging technologies to better understand what is happening in these micro vessels. Others are looking at the biological processes happening in the body in microvascular disease. With better understanding, we’ll be able to develop new treatments.

How do we prevent angina from developing?

I'm working with the medical journal The Lancet on a commission on exactly this issue: How do we get to the point where coronary heart disease stops being a very common disease and it becomes very rare or even disappears?

A big part of the answer is to help people reduce high blood pressure and cholesterol levels and control diabetes, to prevent these risk factors leading to the coronary heart disease, which is one of the main causes of angina.

In recent years we’ve seen the development of exciting new cholesterol-lowering drugs and ones that target diabetes. Also, guidelines are changing so that we’ll be targeting patients to lower their blood pressure and cholesterol levels at an earlier stage.

What made you interested in researching angina? 

I've always been interested in clinical trials and how the results can affect how we actually treat people. I wanted to study a disease that was common and to design clinical trials that would have an impact on the greatest number of people. 

Over a million people in the UK live with angina and it can create a significant burden on their ability to live their lives.

Also, across the world, over 500,000 stenting procedures are done every year to treat angina. This has a big economic burden but importantly it carries some short and long term risks for patients, so we want to make sure we are only performing this procedure for the people who actually stand to benefit from it.  

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