QuickDoc.

Once a diagnosis of Angina has been reached – consider the following:

Secondary prevention:

• Antiplatelet – Aspirin 75mg: if however they have PAD/or stroke, they should be taking Clopidogrel and continue that and not Aspirin (NICE)
• Consider ACEi for those with DM if – coexisting HTN, HF, asymptomatic LVSD, CKD or previous MI
• Statin
• Antihypertensive

For symptom relief:

• As needed Sublingual GTN – Rapid symptom relief and before preforming activities known to cause symptoms of angina
• Regular
  • 1st line Beta-blocker or calcium-channel blocker
    • Beta-blocker – propranolol, acebutolol, atenolol, bisoprolol, carvedilol, metoprolol, nadolol, oxprenolol, pindolol, and timolol
      • There is no good evidence that any one beta-blocker is better than any other in the management of stable angina.
      • If MI – metoprolol (SR), propranolol (SR), timolol or atenolol preferred
      • If HF – bisoprolol, carvedilol or nebivolol preferred
      • Titrate to target/max tolerate dosage
        • Atenolol 100mg OD or 50mg BD (BD may provide better symptom control)
        • Bisoprolol 5-10mg OD
        • Metoprolol 50-100mg (SR) BD or TDS or 200-400mg OD MR
      • Not CI – Avoid if HR < 60BPM
    • CCB as monotherapy if BB CI or not tolerated
      • Diltiazem or verapamil – equally efficacious
  • 2nd line: if both BB and CCB not tolerated or CI
    • Monotherapy with ONE
      • Long acting Nitrate e.g. ISMN
      • Nicorandil
      • Ivabradine
      • Ranolazine
  • If poor symptom control and on single therapy
    • Ensure taking maximum licensed dosage or highest tolerated dosage
    • If on BB
      • Switch to or Add CCB – amlodipine, nifedipine MR, felodipine MR
      • Avoid rate limiting CCB (diltiazem or verapamil) as severe bradycardia or HF can occur
      • If CCB is CI or not tolerated – consider adding
        • Long acting Nitrate e.g. ISMN
        • Nicorandil
        • Ivabradine (if HR > 70) (seek specialist advice)
        • or Ranolazine (seek specialist advice)
    • If on CCB
      • Switch to or add BB
        • Avoid combining BB with rate limiting CCB (diltiazem or verapamil)
      • If BB CI or not tolerated – consider adding
        • Long acting Nitrate e.g. ISMN
        • Nicorandil
        • Ivabradine (if HR > 70) (seek specialist advice)
        • or Ranolazine (seek specialist advice)
  • Poor symptom control on Dual therapy
    • Ensure on Maximum licensed or tolerated dosage of two, if still poor
    • Refer to cardiologist for consideration of revascularization
    • Consider starting third anti-anginal whilst awaiting specialist