stable angina

Question 1

Management (pharmacological)

Answer 1

The management of angina includes modification of cardiovascular risk factors and specific treatment for angina. Treatment of angina should not wait for exercise testing or referral to a cardiologist, even if the drugs have to be stopped for the test.
The patient must be informed of the diagnosis and its implications.

• The patient should be advised that, when an attack of angina occurs, they should:*

1. Stop what they are doing and rest.
2. Use glyceryl trinitrate (GTN) spray or tablets as instructed.
3. Take a second dose of GTN after 5 minutes if the pain has not eased.
4. Take a t_hird dose of GTN after a further 5 minutes_ if the pain has still not eased.
5. Call 999 for an ambulance if the pain has not eased after another 5 minutes (i.e. 15 minutes after onset of pain), or earlier if the pain is intensifying or the person is unwell.

Pharmacological treatment

Offer either a **_beta-blocker_ or _calcium-channel_ blocker as first-line treatment.**
 If the symptoms are nor adequately controlled (or the patient cannot tolerate one option) consider switching to the other option, or using a combination of the two.
 If a patient's symptoms are not adequately controlled on one drug and the other is either contra-indicated or not tolerated, consider adding:
     **A long-acting nitrate.**
     **Ivabradine** ( a selective inhibitor of sinus node pacemaker activity).
  **   Nicorandil.
     Ranolazine** (reduces myocardial ischaemia by acting on intracellular sodium currents).    *_  If using a calcium-channel blocker with either beta-blocker or ivabradine, use a **slow-release nifedipine, amlodipine or felodipine.**_*

If the patient cannot tolerate beta-blockers or calcium-channel blockers (or they are contra-indicated), consider monotherapy with:
A long-acting nitrate
Ivabradine
Nicorandil
Ranolazine

_ Only add a third anti-angina drug when:_
The person’s symptoms are inadequately controlled with two drugs.
The person is waiting for revascularisation or it is not considered appropriate or acceptable.

*When choosing between drugs, make the decision after considering comorbidities, contra-indications, patient preference and drug cost.*

Other treatment:

Unless there is contra-indication, **aspirin should be started**. **Clopidogrel** is an alternative for those who cannot take aspirin but it is much more expensive. Aspirin may be used at doses of 75-300 mg daily.
 Patients **with stable angina and diabetes** should be considered for treatment **ACEI**
 **Statins** should be prescribed **for all** patients **with stable angina due to atherosclerotic disease.**

Question 2

coronary revascularisation

required when?

what should follow the procedure?

Answer 2

Coronary revascularisation is required in those at high risk and those who have failure to be controlled by medical therapy.
A cardiac rehabilitation programme should be arranged following revascularisation

Both coronary artery bypass grafting and percutaneous transluminal angioplasty have their indications and advocates.
 For the low-risk patient with stable angina, medical management carries the lowest risk.

Question 3

definition of stable and unstable angina

Answer 3

Stable angina is when the pain is precipitated by predictable factors - usually exercise.

**Unstable angina: angina occurs at any time** and should be considered and managed as a form of acute coronary syndrome.

Question 4

epidemiology of angina

Answer 4

8% of men and 3% of women aged 55-64 years have, or have had, angina.1
14% of men and 8% of women aged 65-74 years have, or have had, angina.
People of South Asian origin in the UK have an increased risk of ischaemic heart disease