Overall, the main treatment of stable angina is not changed.
What advice should you give patients with angina?
- Pacing activities and physical exertion – including sexual activity
- Prognosis and the likelihood that they would benefit from surgical intervention (see below). Overall mortality is up to 5% per year. MI risk is up to 5% per year.
- To seek advice if their symptoms worsen.
- To call 999 if their angina doesn’t respond to 2 doses of GTN, 5 mins apart.
The British Heart Foundation booklet covers most of the suggested information.
Does surgical intervention alter prognosis?
Stents do not give any survival benefit. CABG can give survival benefit. This is small for multi-vessel disease (at 5 months over 10 yrs), but greater with left main stem disease (LMS) at 19 months over 10 yrs. Only a small number of people who are controlled on medication are likely to have LMS disease (this is likely to be less than 1% of patients). Therefore, if a patient is controlled on medication, you wouldn’t normally do angiography. It is encouraged that we discuss this concept with patients.
What drug treatment is advised for stable angina?
- All patients – Short acting nitrate used before planned exertion.
- 1st line: Beta-blocker or dihydropyridine calcium channel blocker. If one doesn’t work, try the other. If not controlled on one alone, then combine them together.
- 2nd line – if only on a single drug, add in one of:
- Long acting nitrate
- Ivabradine
- Nicorandil (unlicensed use)
- Ranolazine
When should you refer on?
- If the patient is not controlled on 2 drugs as above. It is OK to add in a 3rd drug whilst awaiting further investigation and treatment.
What secondary prevention medications are indicated?
- Aspirin – to all
- Statin – to all
- ACE inhibitor – add in only if the patient also has diabetes or another indication for its use (eg CKD or hypertension). Don’t add in if there is no other indication as it is unlikely to make much difference.
