The information below is based on NICE CG126: Management of stable angina (July 2011)

See also:

NICE TA71: Guidance on the use of coronary artery stents (October 2003)

• Stents should be used routinely when percutaneous coronary intervention (PCI) is the clinically appropriate procedure for people with stable angina

NICE TA152: Drug-eluting stents for the treatment of coronary artery disease (July 2008)

• Drug-eluting stents are recommended for use in percutaneous coronary intervention for treating stable angina, within their instructions for use, only if:
  • the target artery to be treated has less than a 3-mm calibre or the lesion is longer than 15 mm, and
  • the price difference between drug-eluting stents and bare-metal stents is no more than £300

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

• Offer either a beta blocker (atenolol or bisoprolol) or calcium channel blocker (diltiazem M/R) as first-line treatment.
• Do not routinely offer other anti-anginal drugs as first-line treatment

Symptoms not controlled or treatment not tolerated

• Patient on a beta blocker
  • Add or change to amlodipine or felodipine (2.6.2 Calcium-channel blockers)
• 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