Management of angina

Please refer to: NICE CG126: Management of stable angina

Secondary prevention of cardiovascular disease

  • Advice and help to stop smoking
  • Information and advice how other modifiable risk factors can be reduced e.g. physical activity, diet, alcohol, weight and diabetes.
  • Advice and treatment to maintain blood pressure below 140/85mmHg in line with NICE guidance
  • Consider aspirin 75mg (or clopidogrel 75mg if aspirin allergy) See 2.9 Antiplatelet drugs
  • Consider ACE inhibitor for people with stable angina and diabetes. Offer in line with relevant NICE guidance.
  • Statin and dietary advice to lower serum cholesterol in line with relevance NICE guidance, see 2.12 Lipid regulating drugs

Pharmacological management of stable angina

Offer optimal drug treatment:

  • This includes one to two anti-anginal drugs as necessary plus drugs for secondary prevention
  • Review response to therapy after 2-4 weeks
  • Titrate to the maximum tolerated dose

Do not offer a third anti-anginal drug if stable angina is controlled with two

Short-term symptomatic relief

Preventing and treating episodes of angina, immediate short term relief:

  • Short acting sublingual nitrate: Glyceryl trinitrate

First-line treatment

Symptoms not controlled or treatment not tolerated

  • Patient on a beta blocker
  • Patient on first-line calcium channel blocker
    • Change calcium channel blocker to amlodipine or felodipine
  • If beta blockers and calcium channel blockers are contraindicated or not tolerated. Consider monotherapy with either:
    • Isosorbide mononitrate
    • Nicorandil
    • Ivabradine
  • With addition of:
    • Ranolazine - licensed for add-on only. Addition of ranolazine should only be used as a last line option after consideration and/or trial of other therapies

See 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

Choice should be based upon comorbidities, contraindications and cost.

Adding third anti-anginal drug

The addition of a third anti-anginal rarely improves symptom control. Only consider adding a third if not satisfactorily controlled and patient is waiting for revascularisation, or revascularisation is not appropriate or acceptable.

If symptoms are not satisfactorily controlled consider adding or change to:

  • Isosorbide mononitrate or
  • Nicorandil or
  • Ivabradine - when adding to a calcium channel blocker this should be amlodipine or felodipine. It is unlikely to be used in combination with beta blockers or
  • Ranolazine - licensed for add-on only. Ranolazine should only be used as a last line option after consideration and/or trial of other therapies
See 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

 

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