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Stable angina is pain or constricting discomfort that typically occurs in the front of the chest ( but may radiate to the neck , shoulders , jaw or arms ) and is brought on by physical exertion or emotional stress.
Stable angina is common Prevalence increases with age for eg in England it affects ( current or had a hx) ○ 8 % of men and 3 % of women aged 55-65 yrs ○ 14 % of men and 8 % of women aged 65-74 Stable angina predisposes to higher CV mortality Atherosclerotic coronary artery disease ( CAD ) is the commonest cause
Stop or minimise symptoms Improve quality of life Reduce long term morbidity and mortality. complications- Stroke MI Unstable angina Sudden cardiac death psychological
Information and support Follow general principles of treatment
short acting nitrates-Issue sublingual GTN and explain how to use Advice to use before planned exercise or exertion Adverse effects as flushing ,headache and light headedness They can repeat the dose in 5 mins If pain not gone 5 mins after 2nd dose to call emergency ambulance ( ie 10 mins total ) or earlier if pain is intensifying or the person is unwell
Optimal Medical Treatment – defined as one or two antianginal drugs as necessary and secondary prevention of CV disease.Offer a beta blocker or calcium channel blocker as first line Do not offer other anti-anginal as first line. NICE suggests you can use either a beta blocker or CCB ( if one not successful try other ) or use both together When combining CCB and BB use a Dihydropyridine CCB as amlodipine , felodipine or MR Nifedipine
If calcium channel blocker ( CCB ) not tolerated or contra-indicated try beta blocker Licensed for use eg propranolol , acebutalol, atenolol, bisoprolol, carvedilol , metoprolol
Beta blocker contraindicated or not tolerated- try CCB Monotherapy CCB consider a rate limiting CCB as verapamil and diltiazem
If both beta blockers or CCB cannot be used consider single drug treatment with long acting nitrate OR Ivabradine OR Nicorandil OR Ranolazine
Using one drug does not lead to satisfactory control of symptoms consider adding a 2nd drug long acting nitrate OR nicorandil OR ranolazine OR ivabradine
If symptoms controlled with 2 drugs do not offer a 3rd agent Titrate the dose against symptoms up to the max licensed or tolerated dose Review response to treatment 2-4 weeks after starting or changing Only consider a 3 rd agent if ○ symptoms inadequately controlled AND ○ patient is waiting for revascularization or revascularization is not possible
Secondary prevention-Consider aspirin 75 mg ( take into account bleeding risk and co-morbidities ) ○ if on clopidogrel adv to cont with that Consider ACEi for people with angina and diabetes Offer statins as per current guidance Offer hypertension management as per current guidance Advice on smoking Optimise management of co-morbid conditions eg AF, CKD, Diabetes , heart failure, obesity, rheumatoid arthritis and stroke and TIA to reduce risk of CV events
Drugs against angina work by decreasing myocardial oxygen consumption for eg by lowering Heart rate Blood pressure Myocardial loading or Myocardial contractility and / or increasing myocardial blood supply
Calcium channel blockers as effective as beta blockers Long acting nitrates ○ limited evidence ○ development of tolerance Ivrabradine – lowers heart rate by acting on SA node Nicorandil – vasodilator with dual action -leads to relaxation of smoothe tonic vascular muscles in both venous and arterial part of vessels Ranolazine – mechanism of action largely unknown. Possibly works by improving myocardial relaxation and hence decreasing LV diastolic stiffness
Referral-Poor symptom control on maximum licensed or tolerated doses of two drugs ECG suggests extensive ischaemia Previous h/o MI , CABG, stent and development of angina Newly diagnosed AF and angina Heart failure and angina To identify if the person is at high risk and may benefit from revascularization
This will be a decision taken by the cardiology team for people whose symptoms are not adequately controlled by optimal medical treatment. Revascularization can be archived by Coronary artery bypass graft ( CABG ) or Percutaneous coronary intervention ( PCI )
Cardiologist team ( eg cardiac surgeon , interventional cardiologist ) would discuss and explain the patient to help them make an informed decision. Aspects that would be covered would include Main aim is to improve symptoms More tests may be needed Risks and benefits Prognosis without further intervention / investigations Likelihood of left main stem disease or proximal three vessel disease Both CABG and PCI can relieve symptoms Repeat revascularization may be needed ( lower rate for CABG ) Incidence of stroke is same for both ( although uncommon )
References
- Management of stable angina : summary of NICE guidance BMJ 2011 ; 343 :d4147
- Medicine compendium
- Management of stable angina Quick Reference guide NICE July 2011
- CKS NHS angina