Mid Essex Locality Pathway for the Symptomatic Treatment of Stable Angina [See overleaf for criteria for referral to a cardiologist] SHORT TERM CONTROL OF ANGINA SYMPTOMS Sub-lingual glyceryl trinitrate (GTN) should be offered to all patients. It can be used to abort attacks or to provide a short period of prophylaxis while undertaking activities likely to precipitate an angina attack. Patients need to be educated on its appropriate use. DRUG OF CHOICE:- GTN tabs 500mcg (discard 8 weeks after opening) GTN 400mcg sub-lingual CFC-free spray LONG TERM PREVENTION OF ANGINA SYMPTOMS In all cases:- Regular low dose aspirin and GTN prn should be continued Cardiovascular risk factors must be managed e.g. smoking, BP, cholesterol OPTIONS FOR MONOTHERAPY (First-line) 1. Start/Increase 2. Start/Increase 3. Start/Increase Beta Blocker Calcium Channel Blocker Isosorbide Mononitrate People who require regular Diltiazem is the most appropriate symptomatic treatment option if intolerance to beta should be treated with a beta blocker or if there is a C/I. blocker if possible. If beta blocker or diltiazem not If intolerant to or contra- suitable, options include other indicated then Diltiazem is CCBs and nitrates. the preferred next choice Verapamil is an alternative (see start/increase calcium choice, but should be avoided in channel blocker) heart failure, and may cause constipation. PRESCRIBING POINTS:- PRESCRIBING POINTS:- PRESCRIBING POINTS:- Beta blockers should be used with o Newer CCBs offer no significant o ISMN standard tablets are effective caution in asthma or a history of clinical advantages. when used as an eccentrically obstructive airway disease. A small o Nifedipine short-acting formulations dosed twice a day preparation or as dose of a cardioselective beta are not recommended because their a three times a day preparation. blocker (ie Bisoprolol 1.25mg) can use is associated with large variations o Prescribe slow release preparation be given under close observation of in blood pressure and reflex by brand. respiratory symptoms. If well tachycardia. tolerated, they can be up-titrated to o Prescribe nifedipine and diltiazem by the maximum tolerated dose. Beta brand. blockers are contraindicated in decompensated heart failure or critical peripheral vascular disease. DRUGS OF CHOICE:- DRUGS OF CHOICE:- DRUGS OF CHOICE:- Diltiazem (standard release) Isosorbide Mononitrate 60mg three times daily 10 – 40mg bd Atenolol 25mg – 100mg od Amlodipine 5 – 10mg od Nifedipine (modified release) Isosorbide Mononitrate (SR) Metoprolol 25mg – 100mg bd 30 – 60mg in the morning 30 - 60mg in the morning Diltiazem (modified release) Bisoprolol 5 – 10mg od 180 – 360mg daily Verapamil 80 – 120mg three times daily Approved by: Mid Essex Area Prescribing Committee Date: September 2010 Chairman: Dr Alan Jackson Review Date: September 2012 Mid Essex Locality OTHER THERAPIES (following specialist advice) Nicorandil Ivabradine (potassium channel activator) (If inhibitor) As effective as other anti-angina drugs when used A possible treatment option for symptomatic as monotherapy but no more effective. stable patients in sinus rhythm contraindicated It should be reserved for patients who cannot or intolerant of a beta blocker. tolerate or fail to respond to standard alternatives A calcium channel blocker and/or nitrates Headache is a common side-effect. should be tried first where possible. (Diltiazem Nicorandil should be considered as a possible and verapamil have only a limited action on cause in patients who present with symptoms of heart rate in sinus rhythm.) gastrointestinal ulceration Ventricular rate at rest should not be allowed to Ulcers that result from Nicorandil are refractory to fall below 50 beats per minute. treatment; they respond only to withdrawal of Visual symptoms (phosphenes) are a common Nicorandil side-effect and patients should be warned of this. DOSE: Initially 10mg bd (5mg bd if headache); usual dose 10 – 20mg bd; up to 30mg bd may be used DOSE: Initially 5mg bd; increased if necessary after 3-4 weeks to 7.5mg bd (if not tolerated reduce dose to 2.5 – 5mg bd); Elderly initially 2.5mg bd COMBINATION THERAPY MAXIMUM TOLERATED DOSES of monotherapy should be used before moving to combination therapy A beta blocker or alternatively diltiazem should be added to monotherapy if not contraindicated DO NOT COMBINE a beta blocker with verapamil and use caution with diltiazem DO NOT USE verapamil with another calcium channel blocker (CCB) ISMN is suitable for combination with a beta blocker, verapamil or another CCB CCBs are suitable for combination with a beta blocker (other than verapamil and use caution with diltiazem) or a nitrate MAXIMUM tolerated doses of the two anti-angina medications should be tried. There is little evidence that addition of a third drug improves symptom control. If a third drug is introduced while awaiting an outpatient appointment, its effects should be monitored and if it has no effect it should be stopped. RANOLAZINE was considered by the Mid Essex Locality Area Prescribing Committee in September 2010 but was not approved for addition to formulary. Criteria for Referral to a Cardiologist: Patients who may benefit from revascularisation (e.g. failure to respond to medical treatment) Patients with a systolic murmur suggestive of aortic stenosis Patients with previous MI and ongoing angina Patients with uncertain or atypical symptoms Patients with rapidly progressive or unstable angina – HOSPITAL ADMISSION Approved by: Mid Essex Area Prescribing Committee Date: September 2010 Chairman: Dr Alan Jackson Review Date: September 2012 .