Angina Pectoris: Drug Management

Question 1

What should your treatment strategy in treating angina medically?

Answer 1

Optimal drug treatment consists of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease.

Question 2

What drugs should be given for secondary prevention of cardiovascular disease?

Answer 2

• Vigorous lifestyle changes
• Aspirin 75mg OD
• Statin
• If diabetes & stable angina- consider ACEi or A2RB.

Question 3

Everyone with angina symptoms should receive GTN.

When prescribing GTN, what advise should you give?

Answer 3

• Ensure spray is always in date and carried at all times.
• Use immediately before planned exercise or exertion.
• If you develop chest pain, stop activity and take immediately.
• Repeat the dose at 5 minutes - if pain persists call 999.

Question 4

What should you anti-anginal strategy be?

Answer 4

1. Step 1: Offer a first line drug: either a BB or CCB
2. Step 2: if both contraindicated or not tolerated, consider monotherapy with one of the following second line drugs.:
   
   • Long-acting nitrate (ISMN)
   • Ivabradine
   • Nicorandil
   • Ranolazine
3. Step 3: Adding a second drug
   
   • CCB plus BB is preferred combination (see below)
   • If not possible, options are BB or CCB plus one of the second line drugs above.
4. Step 4: If angina not controlled on two drugs, refer for consideration for revascularization.

Question 5

What CCB should be used as first line?

Which BB and CCB combination should be avoided?

Answer 5

• If CCB alone - Use rate limiting CCB like diltiazem or verapamil.
  
  • But if HF or HB - then use amlodipine
• If CCB + BB
  
  • Switch to long acting dihydropyridine CCB- nifedipine MR.
  • But can also use amlodipine or diltiazem safely.

WARNING: DO NOT USE VERAPAMIL + BB.

(RISK OF HEART BLOCK)

Question 6

Which Beta-blockers can used in stable angina?

Answer 6

Any really.

• Atenolol 100mg
• Metoprolol 50-100mg
• Or Bisoprolol 5-20mg

NOTE: They can be used in COPD with mild to moderate airflow obstruction or w/o significant airway reversibility.

Question 7

What are some common side effects of CCB?

Answer 7

• Headache
• Flushing
• Malaise
• Ankle oedema
• Verapamil can cause constipation

Question 8

What are some common side effects of Beta Blockers?

Answer 8

• Bronchospasm
• Fatigue
• Cold peripheries
• Sleep disturbances

Question 9

What are some common side effects of Nitrates?

Answer 9

• Headache
• Postural hypotension
• Tachycardia

Question 10

What are some common side effects of Nicorandil?

Answer 10

• Headache
• Flushing
• Anal ulceration

Question 11

Nitrate tolerance (and thus reduced efficacy) is a common problem. What strategy can be taken?

Answer 11

1. If tolerance develops, then they should take the second dose after 8 hours rather than 12 hours.
2. Or switch to ISMN Modified Release.

Question 12

What are some side effects of ivabradine?

Answer 12

• Visual effects (luminous phenomena)
• Bradycardia (Concomitant use with rate limiting CCB [diltiazem or verapamil] should be avoided)

Question 13

How does Ivabradine work?

Answer 13

• Reduces the heart rate.
• Acts on I_f(funny) channels in the SA node, thus reducing its activity.