ABSTRACT
Chronic refractory angina Chronic refractory angina is a condition which is appropriately and successfully treated in the chronic pain clinic setting. The diagnosis is made where there is angina thought to be due to myocardial ischaemia due to advanced coronary disease despite optimal antianginal medication and where angioplasty or coronary artery bypass surgery have failed or are not feasible. The diagnosis should have been agreed by cardiologist, cardiothoracic surgeon and pain clinician. There should be regular cardiological review to ensure the patient has not developed new disease that needs revascularization and for supervision of antianginal medication. Assessment should ensure that the patient has in fact failed to respond and that poor compliance is not the cause. Similarly, obvious alternative diagnoses such as pain resulting from hyperacidity syndromes of the upper gastrointestinal tract need excluding before further management of the chest pain is contemplated: a trial of proton pump inhibitor should be considered. Pharmacological treatment should be rationalized in a multidisciplinary setting. A psychosocial history will help identify stressors and inappropriate beliefs, as well as helping to identify depression and anxiety.
