Drug Treatment for Stable Angina

Drug Treatment for Stable Angina

• Prescribe sublingual glyceryl trinitrate (GTN) for rapid relief of angina symptoms and for use before performing activities known to cause symptoms.
• Instruct the person that if they experience chest pain they should:
  • Stop what they are doing and rest.
  • Use GTN spray or tablets as instructed.
  • Take a second dose after 5 minutes if the pain has not eased.
  • Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell.
• Prescribe a beta-blocker or a calcium-channel blocker (CCB) as first-line regular treatment to reduce symptoms of stable angina, depending on the person's comorbidities, contraindications, and preference.
  • If the person cannot tolerate the beta-blocker or CCB, consider switching to the other option.
• If both beta-blockers and CCBs are contraindicated or not tolerated, consider monotherapy with one of the following drugs:
  • A long-acting nitrate (such as isosorbide mononitrate).
  • Nicorandil.
• Ivabradine and Ranolazine may be used to treat stable angina where beta-blockers and CCBs are contraindicated or not tolerated.
• Titrate the dose against symptoms, where necessary up to the maximum licensed or tolerated dose.
• Review response to drug treatment 2-4 weeks after starting or changing it, including any adverse effects.

Drug Treatment for Secondary Prevention

• Consider antiplatelet treatment in all people with stable angina, taking into account the person's risk of bleeding and comorbidities.
  • For most people this will be low-dose aspirin (75mg daily).
  • People with stroke or peripheral arterial disease should continue taking clopidogrel rather than aspirin.
• Consider treatment with an angiotensin-converting enzyme (ACE) inhibitor for people with stable angina and diabetes mellitus.
• Ensure that people with coexisting hypertension, heart failure, asymptomatic left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction have been prescribed an ACE inhibitor in line with current guidance unless this is contraindicated or not tolerated.

Lifestyle Modification

• Advise and assist all people who smoke to stop.
• Encourage people to eat a cardioprotective diet.
• Do not offer vitamin or fish oil supplements to treat stable angina.
• Offer advice and support to achieve and maintain a healthy weight to people who are overweight or obese.
• Encourage people to increase their physical activity levels within the limits set by their symptoms.

Important Note

• The aim of anti-anginal drug treatment is to prevent episodes of angina.
• The aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke.
• Optimize management of comorbid conditions that present an increased risk of cardiovascular events.

Angina Drug Treatment

• Ivabradine and Ranolazine are treatments for Angina
• Review response to treatment 2-4 weeks after starting or changing drug treatment
• Titrate dose against symptoms to reach maximum licensed or tolerated dose
• If there is a poor response to treatment, refer to "Poor control on treatment" scenario

Angina Secondary Prevention

• Consider antiplatelet treatment for all people with stable angina
• Low dose aspirin (75 mg daily) is the most common antiplatelet treatment
• People with stroke or peripheral arterial disease should be taking clopidogrel rather than aspirin
• For antiplatelet prophylaxis, see CKS topic on Antiplatelet treatment.
• Consider ACE inhibitor treatment for people with stable angina and diabetes mellitus
• Refer to ACE inhibitor treatment guidelines for people with coexisting hypertension, heart failure, asymptomatic left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction
• Offer a statin for lipid modification
• Offer antihypertensive treatment

Angina Referral

• Consider hospital admission for people experiencing angina at rest, minimal exertion, or rapidly progressing symptoms
• Refer to a cardiologist for people with:
  • Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty and development of angina
  • ECG evidence of previous myocardial infarction or other significant abnormality
  • Newly diagnosed atrial fibrillation and angina
  • Heart failure and angina
  • Ejection systolic murmur suggesting aortic stenosis
  • Any suggestion of hypertrophic cardiomyopathy
  • Doubt about the diagnosis
  • Presence of several risk factors or a strong family history
  • The person's preference for referral

Angina Cardiovascular Risk Management

• All people with angina are considered high risk for cardiovascular events
• Manage comorbid conditions such as atrial fibrillation, chronic kidney disease, diabetes, heart failure, hypertension, obesity, rheumatoid arthritis, and stroke
• Advise and assist smokers to stop smoking
• Encourage people to eat a cardioprotective diet
• Avoid vitamin and fish oil supplements, as they are not proven to help stable angina
• Offer weight management support to overweight or obese people
• Encourage people to increase physical activity levels within the limits of their symptoms, consult CKS topic "CVD risk assessment and management" for recommended activity levels
• Encourage people to limit alcohol consumption: advise men and women to limit alcohol intake to 14 units a week and spread this evenly over 3 days or more

Angina and Work

• Many people with angina can continue to work as before
• People with heavy manual labor jobs will potentially need to adjust work practices
• People with driving jobs should consult the DVLA
• People with employers with occupational health departments should consult them to discuss any issues
• Refer to British Heart Foundation (BHF) publications for further information

Angina and Driving

• People with angina have a responsibility to inform the DVLA of any condition that may affect their ability to drive
• For group 1 entitlement (cars, motorcycles):
  • Driving must cease when symptoms occur at rest, with emotion, or whilst driving
  • Driving may recommence when satisfactory symptom control is achieved
  • The DVLA need not be notified
• For group 2 entitlement (lorries, buses):
  • The person must not drive and must notify the DVLA when symptoms occur
  • Refusal or revocation of a driver's license may occur if symptoms continue
  • Re-licensing may be permitted after 6 weeks free from angina, provided exercise/functional test requirements can be met, and there are no disqualifying conditions
• Check with insurance company to ensure coverage is appropriate with an angina diagnosis

Angina and Sex

• Many people with angina continue sexual intercourse without complications
• Sublingual GTN taken immediately before intercourse can help prevent anginal episodes
• Concomitant use of nitrates or nicorandil with phosphodiesterase inhibitors is generally contraindicated
• If concurrent use is considered essential, advise people taking phosphodiesterase inhibitors on the wait time between doses of medication and nitrates
• Avoid GTN if an anginal attack occurs during sexual intercourse and contact emergency medical services (999) if pain does not resolve within 10 minutes

Angina and Air Travel

• Individualize air travel advice based on symptom severity
• Chest pain on considerable exertion with no recent changes in symptoms or medication: no air travel restriction
• Chest pain on minimal exertion with no recent changes in symptoms or medication: consider airport assistance and in-flight oxygen
• Chest pain at rest or changes in symptoms or medication: defer travel until stable, travel with medical escort and ensure in-flight oxygen is available

This quiz covers the essential drug treatments for stable angina, including the use of glyceryl trinitrate (GTN) for rapid symptom relief. It also discusses the role of beta-blockers and calcium-channel blockers in managing symptoms, and the necessary steps to take during an angina episode. Test your knowledge on managing stable angina effectively!