Management of Stable Angina in Adults

Home , Isosorbide mononitrate, Nicorandil

For new onset chest pain where angina is suspected patients should be referred to Rapid Access Chest Pain Service.

ANTIANGINAL DRUG TREATMENT *see West Essex formulary for further choices Monotherapy: Beta blocker [Bisoprolol*] OR Calcium channel blocker (CCB) [Amlodipine*] N.B. In left-ventricular dysfunction (LVD), beta blocker therapy should be started at a low dose and titrated very slowly over a period of weeks or months.

If beta-blockers or CCBs are not tolerated or both are contra- If a beta-blocker or Calcium Channel Blocker is indicated consider monotherapy with: contraindicated or not tolerated or symptoms are not  a long-acting nitrate e.g. Isosorbide mononitrate MR

controlled with a beta-blocker or CCB:  Nicorandil

Switch to the alternative drug  Ivabradine (Restricted use – consultant initiation) or  Ranolazine (Restricted use – consultant initiation) Do not combine ivabradine with a rate-limiting CCB, because it can Dual therapy: result in excessive bradycardia. Beta blocker AND Calcium Channel Blocker If symptoms are not controlled with a beta-blocker or If symptoms are not controlled with a beta-blocker or CCB alone DRUG THERAPY DRUG CCB, and neither are contraindicated: give a beta- and the other drug is contraindicated or not tolerated ADD: blocker AND CCB in combination.  a long-acting nitrate or  Nicorandil Do not combine a beta-blocker with a rate limiting CCB, as severe bradycardia and heart failure can  Ivabradine (Restricted use – consultant initiation) or occur.3  Ranolazine (Restricted use – consultant initiation)

NOTE Assess response to treatment 2-4 weeks after initiating or changing drug therapy; the drug should be titrated (according to symptom control) to the maximum tolerated dose.

Nitrates Give all patients a short-acting nitrate [e.g. Glyceryl Trinitrate tablets sublingual 500micrograms or CFC-free spray 400micrograms – (Coro-Nitro Pump Spray®), as required], for preventing and treating episodes of angina. Advise patient: when using GTN to treat episodes of angina, the dose can be repeated after 5 minutes if the pain has not gone. If the pain has not gone 5 minutes after second dose, call emergency services. NOTE: Sublingual GTN may also be taken immediately before performing activities that are known to bring on an attack. If attacks occur more than twice a week, regular drug therapy is required and should be introduced using a

ACUTE ATTACKS ACUTE step-wise approach according to patient response.

SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE  Consider Aspirin 75mg daily. Take into account risk of bleeding and comorbidities. Advise patient - Secondary prevention aims to prevent cardiovascular events e.g. heart attack and stroke.

 Consider Angiotensin-converting enzyme (ACE) inhibitors for people with stable angina and diabetes. Offer or continue ACE inhibitors for other conditions, in line with relevant NICE guidance.  Offer Statins in line with ‘Lipid Modification’ (NICE CG181)  Offer treatment for high blood pressure in line with ‘Hypertension’ (NICE CG127).

References 1. NICE CG126 Management of stable angina. Published July 2011; Last updated August 2016 http://www.nice.org.uk/CG126

2. BNF https://bnf.nice.org.uk/ [Accessed 31.10.18] 3. NICE CKS Summaries Angina. Last revised January 2018 https://cks.nice.org.uk/angina 4. NICE QS21 Stable angina. Published August 2012; Last updated February 2017 https://www.nice.org.uk/guidance/qs21

Produced by West Essex CCG Medicines Optimisation Team ; Produced May 2014; Updated and Approved Sept 2019; Review date Sept 2021