- Rapid symptom control – as needed sublingual GTN.
1st line BB or CCB as regular medication
- Beta-blocker – propranolol, acebutolol, atenolol, bisoprolol, carvedilol, metoprolol, nadolol, oxprenolol, pindolol, and timolol.
- There is no good evidence that any one beta-blocker is better than any other in the management of stable angina.
- If MI – metoprolol (SR), propranolol (SR), timolol or atenolol preferred.
- If HF – bisoprolol, carvedilol or nebivolol preferred.
- Titrate to target/max tolerate dosage
- Atenolol 100mg OD or 50mg BD (BD may provide better symptom control)
- Bisoprolol 5-10mg OD
- Metoprolol 50-100mg (SR) BD or TDS, or 200-400mg OD MR
- Avoid if HR < 60BPM
- CCB as monotherapy if BB CI or not effective.
- Diltiazem or verapamil – equally efficacious.
2nd line options if both BB and CCB not tolerated or contraindicated.
- Monotherapy with one of:
- Long acting Nitrate e.g. ISMN
- Nicorandil
- Ivabradine
- Ranolazine
If poor symptom control, and on single therapy.
- Ensure taking maximum licensed dosage or highest tolerated dosage.
- If on BB
- Switch to, or add CCB – amlodipine, nifedipine MR, felodipine MR
- Avoid rate limiting CCB (diltiazem or verapamil) as severe bradycardia or HF can occur.
- If CCB is contraindicated or not tolerated – consider adding:
- Long acting Nitrate e.g. ISMN
- Nicorandil
- Ivabradine (if HR > 70) (seek specialist advice)
- or Ranolazine (seek specialist advice)
- If on CCB
- Switch to or add BB
- Avoid combining BB with rate limiting CCB (diltiazem or verapamil)
- If BB CI or not tolerated, consider adding:
- Long acting Nitrate e.g. ISMN
- Nicorandil
- Ivabradine (if HR > 70) (seek specialist advice)
- or Ranolazine (seek specialist advice)
- Switch to or add BB
Poor symptom control on dual therapy.
- Ensure on maximum licensed or tolerated dosage of two, if still poor…
- Refer to cardiologist for consideration of revascularization
- Consider starting third anti-anginal whilst awaiting specialist
Secondary prevention
- Consider ACEi for those with DM if coexisting HTN, HF, asymptomatic LVSD, CKD or previous MI
- Antiplatelet – Aspirin 75mg. If have PAD/or stroke, they should be taking Clopidogrel, continue that and not Aspirin (NICE)
- Statin
- Antihypertensives