Pharmacists are ideally placed to counsel angina patients to enable them to obtain maximum benefit from their drug treatment and to also minimise cardiovascular risk factors. Patients can be counselled as part of an advanced service such as an MUR or NMS, or opportunistically within the pharmacy.

Nitrates

Patients prescribed glyceryl trinitrate tablets or spray should be advised to carry their treatment with them at all times and ensure that the product has not date expired.

GTN tablets lose their potency and must be replaced 8 weeks after opening the bottle. For both GTN tablets and sprays it is essential that a new prescription is obtained before the old one expires.

Patients should also consider that they may need to use their GTN treatment at short notice, possibly in the dark. To ensure they are familiar with using their treatment they should be encouraged to practice its use, such as by spraying the product into the air.

Periodically ensuring that the product still works correctly if not used for a week or more will ensure that it will be effective if needed.

An increased frequency of requests for GTN preparations could indicate that the patient's condition is deteriorating and that treatment should be reviewed.

Patients prescribed GTN should be advised that alcohol can increase the effects, and side effects, of their GTN. Alcohol may potentiate headache.

Lifestyle advice

Specific advice for each of these criteria is discussed in more detail in the Pharmacy Excellence module 'Cardiovascular disease: risk assessment'.

Lifestyle impact

A diagnosis of angina can have a significant impact on a patient's quality of life, causing anxiety and depression. The diagnosis can impact on many areas of the patient's life including diet, work, flying, sexual activity, exercise and the ability to drive. Pharmacists should be prepared to discuss or advise on these impacts and sign post for further advice where necessary.

The following summarises suitable advice to provide in each scenario.

Advice on work

Many patients diagnosed with angina continue to work in the same way as they did prior to diagnosis. Patients whose job involves heavy manual work may need to change their working patterns. Those whose job involves driving should be advised to consult the DVLA.

All patients should be encouraged to consult their employer's occupational health department, where available, to discuss any specific work related issues with them.¹

Advice on driving

DVLA rules regarding driving differ dependent on the category of motor vehicle the patient drives.

For group one entitlement i.e. cars or motorcycles patients with angina do not need to notify DVLA but they should be advised to stop driving when angina symptoms occur at rest, with emotion or at the wheel. Driving can only recommence once symptoms are satisfactorily controlled.¹

Advice on diet

Patients diagnosed with angina should be encouraged to eat healthily, by adopting a cardioprotective diet, to reduce the risk of their angina getting worse. Suitable dietary advice would include:

• Try to eat at least 5 portions of fruit and vegetables daily.
• Restrict salt, sugar and saturated fat intake.
• Do not drink above recommended alcohol levels.
• Change your diet gradually, choose up to two or three changes at a time.
• Try to adopt a "Mediterranean diet" which consists of less meat and having fish, fruit, vegetables, grains, nuts, pulses and beans in the diet.

Advice on exercise

Patients diagnosed with stable angina should be encouraged to exercise to reduce the chances of further cardiovascular events.

However, patients should be advised not to exercise so hard that they develop symptoms of angina, to avoid exercising in the cold or strong winds or when they are experiencing chest pain.

Patients should ask their GP or nurse for advice on a suitable level of exercise and to gradually build up the level of exercise. Patients may be advised to take sublingual glyceryl trinitrate prior to exercising.¹

Advice on sexual activity

Patients who can briskly climb up or down two flights of stairs without experiencing chest pain can be advised that sexual activity is unlikely to provoke angina symptoms.

If sexual activity provokes symptoms patients can be advised that sublingual GTN taken immediately prior to sexual activity may help to prevent further attacks. This would contra-indicate the use of a PDE-5 inhibitor.

Patients who have taken a PDE-5 inhibitor who then experience angina symptoms during sexual intercourse should be advised to stop sexual activity and rest for 5-10 minutes. If the pain does not ease they should dial 999. They should not use GTN to relieve the angina symptoms.¹

Advice on flying

The advice provided to patients on their suitability to fly will be determined by the severity of their symptoms:

• Patients who experience chest pain only after considerable exertion and have had no change to symptoms or medication can be advised there is no restriction on flying.
• Patients who experience chest pain on minimal exertion with no change in medication or symptoms should consider airport assistance and in-flight oxygen.
• Patients with chest pain at rest, change in symptoms and/or medication should consider deferring travel until their condition is stable. Patients who decide to travel should have a medical escort and ensure in-flight oxygen is available.¹