Angina pectoris: drug management

Angina pectoris: drug management

• all patients should receive aspirin and a statin in the absence of any contraindication
• sublingual glyceryl trinitrate
  sublingual glyceryl trinitrate
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  to abort angina attacks
• NICE recommend using either a beta-blocker or a calcium channel blocker
  A beta-blocker or a calcium channel blocker is used first-line to prevent angina attacks
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  Importance: 81
  first-line based on 'comorbidities, contraindications and the person's preference'
• if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used
• if used in combination with a beta-blocker then use a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine)
  • remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
• if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose
  When treating angina, if there is a poor response to the first-line drug (e.g. a beta-blocker), the dose should be titrated up before adding another drug
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  Importance: 77
  (e.g. for atenolol 100mg od)
• if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker
  If angina is not controlled with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be added
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  Importance: 49
  and vice versa
• if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs:
  • a long-acting nitrate
  • ivabradine
  • nicorandil
  • ranolazine
• if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

• many patients who take nitrates develop tolerance and experience reduced efficacy
• NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval
  Asymmetric dosing regimes should be used for standard-release ISMN to prevent nitrate tolerance
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  Importance: 47
  to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
• this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate