Download Stable Angina: Sympotomatic Treatment - Sept 2010

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
Beta Blocker
2. Start/Increase
Calcium Channel Blocker
 People who require regular
symptomatic treatment
should be treated with a beta
blocker if possible.
 If intolerant to or contraindicated then Diltiazem is
the preferred next choice
(see start/increase calcium
channel blocker)
 Diltiazem is the most appropriate
option if intolerance to beta
blocker or if there is a C/I.
 If beta blocker or diltiazem not
suitable, options include other
CCBs and nitrates.
 Verapamil is an alternative
choice, but should be avoided in
heart failure, and may cause
constipation.
3. Start/Increase
Isosorbide Mononitrate
PRESCRIBING POINTS:-
PRESCRIBING POINTS:-
PRESCRIBING POINTS:-
Beta blockers should be used with
caution in asthma or a history of
obstructive airway disease. A small
dose of a cardioselective beta
blocker (ie Bisoprolol 1.25mg) can
be given under close observation of
respiratory symptoms. If well
tolerated, they can be up-titrated to
the maximum tolerated dose. Beta
blockers are contraindicated in
decompensated heart failure or
critical peripheral vascular disease.
o Newer CCBs offer no significant
clinical advantages.
o Nifedipine short-acting formulations
are not recommended because their
use is associated with large variations
in blood pressure and reflex
tachycardia.
o Prescribe nifedipine and diltiazem by
brand.
o ISMN standard tablets are effective
when used as an eccentrically
dosed twice a day preparation or as
a three times a day preparation.
o Prescribe slow release preparation
by brand.
DRUGS OF CHOICE:-
DRUGS OF CHOICE:-
DRUGS OF CHOICE:-
Diltiazem (standard release)
60mg three times daily
Amlodipine 5 – 10mg od
Nifedipine (modified release)
30 – 60mg in the morning
Diltiazem (modified release)
180 – 360mg daily
Verapamil
80 – 120mg three times daily
Isosorbide Mononitrate
10 – 40mg bd
Atenolol 25mg – 100mg od
Metoprolol 25mg – 100mg bd
Bisoprolol 5 – 10mg od
Approved by: Mid Essex Area Prescribing Committee
Chairman: Dr Alan Jackson
Isosorbide Mononitrate (SR)
30 - 60mg in the morning
Date: September 2010
Review Date: September 2012
Mid Essex Locality
OTHER THERAPIES (following specialist advice)
Nicorandil
(potassium channel activator)
 As effective as other anti-angina drugs when used
as monotherapy but no more effective.
 It should be reserved for patients who cannot
tolerate or fail to respond to standard alternatives
 Headache is a common side-effect.
 Nicorandil should be considered as a possible
cause in patients who present with symptoms of
gastrointestinal ulceration
 Ulcers that result from Nicorandil are refractory to
treatment; they respond only to withdrawal of
Nicorandil
DOSE:
Initially 10mg bd (5mg bd if headache); usual dose
10 – 20mg bd; up to 30mg bd may be used
Ivabradine
(If inhibitor)
 A possible treatment option for symptomatic
stable patients in sinus rhythm contraindicated
or intolerant of a beta blocker.
 A calcium channel blocker and/or nitrates
should be tried first where possible. (Diltiazem
and verapamil have only a limited action on
heart rate in sinus rhythm.)
 Ventricular rate at rest should not be allowed to
fall below 50 beats per minute.
 Visual symptoms (phosphenes) are a common
side-effect and patients should be warned of
this.
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
Chairman: Dr Alan Jackson
Date: September 2010
Review Date: September 2012