NICE Angina - New Diagnosis PDF

**What information and support should I provide for a person with stable angina?** - **Provide information and support for people with newly diagnosed angina.** - Clearly explain the diagnosis of stable angina to the person. The explanation should include: - Factors...

**What information and support should I provide for a person with stable angina?** - **Provide information and support for people with newly diagnosed angina.** - Clearly explain the diagnosis of stable angina to the person. The explanation should include: - Factors which can provoke angina, such as exertion, emotional stress, exposure to cold, or eating a large meal. - The long-term progression and prognosis of angina. - Information on how angina is managed. - Encourage the person to ask questions about their angina and its management. - Explore and address any misconceptions the person might have about their angina. This includes: - Implications for daily activities. - Risk of myocardial infarction. - Life expectancy. - Advise the person to seek medical help if there is a sudden worsening in the frequency or severity of their angina. - Discuss the reasons for treatment, as well as the benefits and adverse effects (such as flushing, headache, and light-headedness). For more information, see the section on [Prescribing information](https://cks.nice.org.uk/topics/angina/prescribing-information/). - Provide information on how to use a short-acting sublingual nitrate and when to administer it.  - Assess the person\'s need for lifestyle advice to manage their [cardiovascular risk](https://cks.nice.org.uk/topics/angina/background-information/risk-factors/). - Explore and address issues according to the person\'s needs, which may include: - Self-management skills such as pacing their activities and goal setting. - Concerns about the impact of stress, anxiety, or depression on angina. - Advice about physical exertion including [sexual activity](https://cks.nice.org.uk/topics/angina/management/new-diagnosis/#advice-on-sexual-activity). - Advice about other activities such as [driving](https://cks.nice.org.uk/topics/angina/management/new-diagnosis/#advice-on-driving), [flying](https://cks.nice.org.uk/topics/angina/management/new-diagnosis/#advice-on-flying), and [work](https://cks.nice.org.uk/topics/angina/management/new-diagnosis/#advice-on-work). - Advise people that the aim of [anti-anginal drug treatment](https://cks.nice.org.uk/topics/angina/management/new-diagnosis/#drug-treatment) is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke. **What drug treatments should I prescribe for a person with stable angina?** - **Drug treatment for symptom relief:** - **Prescribe [sublingual glyceryl trinitrate](https://cks.nice.org.uk/topics/angina/prescribing-information/nitrates/) (GTN) for the rapid relief of symptoms of angina **and for use before performing activities known to cause symptoms of angina. - Instruct the person that if they experience chest pain they should: - Stop what they are doing and rest. - Use their glyceryl trinitrate 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](https://cks.nice.org.uk/topics/angina/prescribing-information/beta-blockers/) or a [calcium-channel blocker](https://cks.nice.org.uk/topics/angina/prescribing-information/calcium-channel-blockers/) (CCB) as first-line regular treatment **to reduce the symptoms of stable angina, depending on the person\'s comorbidities, contraindications, and preference.  - If the person cannot tolerate the beta-blocker or calcium-channel blocker, consider switching to the other option (calcium-channel blocker or beta-blocker). - **If both beta-blockers and CCBs are [contraindicated](https://cks.nice.org.uk/topics/angina/prescribing-information/beta-blockers/#contraindications-cautions) or not tolerated, **consider monotherapy with *one *of the following drugs. Decide which drug to use based on comorbidities, contraindications, the person\'s preference, and cost: - A long-acting [nitrate](https://cks.nice.org.uk/topics/angina/prescribing-information/nitrates/) (such as isosorbide mononitrate). - [Nicorandil](https://cks.nice.org.uk/topics/angina/prescribing-information/nicorandil/). - [Ivabradine](https://cks.nice.org.uk/topics/angina/prescribing-information/ivabradine/). - [Ranolazine](https://cks.nice.org.uk/topics/angina/prescribing-information/ranolazine/). - **Review response to treatment, **including any adverse effects, 2--4 weeks after starting or changing drug treatment. - Titrate the dose against symptoms, where necessary up to the maximum licensed or tolerated dose. - If there is a poor response to treatment, see the scenario [Poor control on treatment](https://cks.nice.org.uk/topics/angina/management/poor-control-on-treatment/). - **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 (75 mg daily) --- people with stroke or peripheral arterial disease should already be taking clopidogrel rather than aspirin, and should continue taking clopidogrel. - For information on antiplatelet prophylaxis, including advice on what to do if the person is allergic to aspirin or is at risk of gastrointestinal adverse effects, see the CKS topic on [Antiplatelet treatment](https://cks.nice.org.uk/topics/antiplatelet-treatment/). - **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. - For more information, see the CKS topics on [Chronic kidney disease](https://cks.nice.org.uk/topics/chronic-kidney-disease/), [Diabetes - type 1](https://cks.nice.org.uk/topics/diabetes-type-1/), [Diabetes - type 2](https://cks.nice.org.uk/topics/diabetes-type-2/), [Heart failure - chronic](https://cks.nice.org.uk/topics/heart-failure-chronic/), [Hypertension](https://cks.nice.org.uk/topics/hypertension/), and [MI - secondary prevention](https://cks.nice.org.uk/topics/mi-secondary-prevention/). - Offer a statin. For further information see the CKS topic on [Lipid modification - CVD prevention](https://cks.nice.org.uk/topics/lipid-modification-cvd-prevention/). - Offer antihypertensive treatment. For more information, see the CKS topic on [Hypertension](https://cks.nice.org.uk/topics/hypertension/). **When should I refer a person with newly diagnosed angina?** - **Consider hospital admission for people with the following symptoms, as they may have unstable angina:** - Pain at rest (which may occur at night). - Pain on minimal exertion. - Angina that seems to be progressing rapidly despite increasing medical treatment. - **Indications for early referral to a cardiologist include:** - Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty and development of angina. - ECG (electrocardiographic) evidence of previous myocardial infarction or other significant abnormality. - Newly diagnosed atrial fibrillation and angina. - Heart failure and angina. - An ejection systolic murmur suggesting aortic stenosis. - Any suggestion of hypertrophic cardiomyopathy (for example by family history, physical examination, or ECG). - **Further reasons to refer people to a cardiologist include:** - Doubt about the diagnosis. - The presence of several risk factors or a strong family history. - The person\'s preference for referral. **How should I manage the cardiovascular risk in a person with angina?** All people with angina are assumed to be at high risk for cardiovascular events, and their cardiovascular risk factors should be managed accordingly. - **Optimize the management of comorbid conditions that present an increased risk of cardiovascular events, **such as [Atrial fibrillation](https://cks.nice.org.uk/topics/atrial-fibrillation/), [Chronic kidney disease](https://cks.nice.org.uk/topics/chronic-kidney-disease/), [Diabetes - type 1](https://cks.nice.org.uk/topics/diabetes-type-1/), [Diabetes - type 2](https://cks.nice.org.uk/topics/diabetes-type-2/), [Heart failure - chronic](https://cks.nice.org.uk/topics/heart-failure-chronic/), [Hypertension](https://cks.nice.org.uk/topics/hypertension/), [Obesity](https://cks.nice.org.uk/topics/obesity/), [Rheumatoid arthritis](https://cks.nice.org.uk/topics/rheumatoid-arthritis/), and [Stroke and TIA](https://cks.nice.org.uk/topics/stroke-tia/). - **Advise and assist all people who smoke to stop. **For more information, see the CKS topic on [Smoking cessation](https://cks.nice.org.uk/topics/smoking-cessation/). - **Encourage people to eat a cardioprotective diet. **For more information, see the section on [Secondary prevention](https://cks.nice.org.uk/topics/mi-secondary-prevention/management/secondary-prevention/) in the CKS topic on [MI - secondary prevention](https://cks.nice.org.uk/topics/mi-secondary-prevention/). - Do not offer vitamin or fish oil supplements to treat stable angina --- inform people that there is no evidence that they help stable angina. - **Offer advice and support to achieve and maintain a healthy weight **to people who are overweight or obese. For more information, see the CKS topic on [Obesity](https://cks.nice.org.uk/topics/obesity/). - **Encourage people to increase their physical activity levels within the limits set by their symptoms. **For more information on the recommended levels of physical activity for cardiovascular protection, see the section on [Lifestyle advice](https://cks.nice.org.uk/topics/cvd-risk-assessment-management/management/cvd-risk-less-than-10percent/#lifestyle-advice) in the CKS topic on [CVD risk assessment and management](https://cks.nice.org.uk/topics/cvd-risk-assessment-management/). - **Encourage people to limit their alcohol consumption.** - Advise men and women to limit their alcohol intake to 14 units a week and to spread this evenly over 3 days or more.  - For more information, see the CKS topic on [Alcohol - problem drinking](https://cks.nice.org.uk/topics/alcohol-problem-drinking/). **What advice should I give about work?** - Advise people with angina that: - Many people with angina can continue to work as before. - If their job involves heavy manual work, they may need to alter their work practices. - If their job involves [driving](https://cks.nice.org.uk/topics/angina/management/new-diagnosis/#advice-on-driving), they should consult the Driver and Vehicle Licensing Agency (DVLA). - If the person\'s employer has an occupational health department, they should be encouraged to discuss any issues with them. - Further information is available from the [British Heart Foundation (BHF](https://www.bhf.org.uk/)) which produces the booklets [Returning to work with a heart condition](https://www.bhf.org.uk/informationsupport/publications/heart-conditions/returning-to-work-with-a-heart-condition) and [Angina](https://www.bhf.org.uk/informationsupport/publications/heart-conditions/angina). **What advice should I give about driving?** - Advise the person that it is their responsibility to inform the Driver and Vehicle Licensing Agency (DVLA) of any condition that may affect their ability to drive. - The DVLA\'s medical rules regarding angina are: - **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 licence may occur if symptoms (treated or untreated) continue. - Re-licensing may be permitted thereafter, provided that the person has been free from angina for at least 6 weeks, exercise or other functional test requirements can be met, and there is no other disqualifying condition. - The person should check with their insurer to ensure that their insurance cover is appropriate with a diagnosis of angina. **What advice should I give about sexual activity?** - Advise the person that many people with angina continue sexual intercourse, and that it is just as safe as other equally energetic forms of exercise. - If sexual activity does precipitate an episode of angina, sublingual glyceryl trinitrate (GTN) taken immediately before intercourse may help prevent subsequent attacks. - The concomitant use of nitrates or nicorandil with phosphodiesterase inhibitors (avanafil, sildenafil, vardenafil, and tadalafil), often used in the treatment of erectile dysfunction, is generally contraindicated. - Where concurrent use is considered to be medically essential, advise people who take a phosphodiesterase inhibitor that: - There should be at least 12 hours between a dose of avanafil and a nitrate, 24 hours between a dose of sildenafil and a nitrate, and 48 hours between a dose of tadalafil and a nitrate. Concurrent use of nitrates and vardenafil is contraindicated. - If they have an episode of angina during sexual intercourse, they must not use glyceryl trinitrate (GTN). They should stop sexual activity and, if their pain does not resolve within 10 minutes, they should call 999 for an ambulance. **What advice should I give about air travel?** - Give the person the following advice depending on the severity of their angina symptoms: - Chest pain on considerable exertion with no recent change in symptoms or medication --- no restriction on air travel. - Chest pain on minimal exertion with no recent change of symptoms or medication --- consider airport assistance and possible in-flight oxygen. - Chest pain at rest or a change in symptoms and/or medication --- defer travel until stable, or travel with a medical escort and ensure in-flight oxygen is available