Management of Stable Angina in Adults 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 Do not combine a beta-blocker with a rate limiting Nicorandil 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 .