Stable Angina: Management

This guideline covers managing stable angina in people aged 18 years and over.

This Guidelines summary only covers recommendations for primary care. Refer to the full guideline for a complete set of recommendations, including recommendations on investigation, revascularisation, and cardiac syndrome X.

Diagnosis

• Diagnose stable angina according to Chest pain of recent onset (NICE clinical guideline 95). Diagnose and manage unstable angina and NSTEMI according to Chest pain of recent onset (NICE clinical guideline 95), Unstable angina and NSTEMI (NICE clinical guideline 94) and MI: secondary prevention (NICE clinical guideline 48).

Information and Support for People With Stable Angina

• Clearly explain stable angina to the person, including factors that can provoke angina (for example, exertion, emotional stress, exposure to cold, eating a heavy meal) and its long-term course and management. When relevant, involve the person's family or carers in the discussion
• Encourage the person with stable angina to ask questions about their angina and its treatment. Provide opportunities for them to voice their concerns and fears
• Discuss the person's, and if appropriate, their family or carer's ideas, concerns and expectations about their condition, prognosis and treatment. Explore and address any misconceptions about stable angina and its implications for daily activities, heart attack risk and life expectancy
• Advise the person with stable angina to seek professional help if there is a sudden worsening in the frequency or severity of their angina
• Discuss with the person the purpose and any risks and benefits of their treatment
• Assess the person's need for lifestyle advice (for example about exercise, stopping smoking, diet and weight control) and psychological support, and offer interventions as necessary
• Explore and address issues according to the person's needs, which may include:
  • self-management skills such as pacing their activities and goal setting
  • concerns about the impact of stress, anxiety or depression on angina
  • advice about physical exertion including sexual activity.

General Principles for Treating People With Stable Angina

• Do not exclude people with stable angina from treatment based on their age alone
• Do not investigate or treat symptoms of stable angina differently in men and women or in different ethnic groups.

Preventing and Treating Episodes of Angina

• Offer a short-acting nitrate for preventing and treating episodes of angina. Advise people with stable angina:
  • how to administer the short-acting nitrate
  • to use it immediately before any planned exercise or exertion
  • that side-effects such as flushing, headache and light-headedness may occur
  • to sit down or find something to hold on to if feeling light-headed
• When a short-acting nitrate is being used to treat episodes of angina, advise people:
  • to repeat the dose after 5 minutes if the pain has not gone
  • to call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose.

Drugs for Secondary Prevention of Cardiovascular Disease

• Consider aspirin 75 mg daily for people with stable angina, taking into account the risk of bleeding and comorbidities
• Consider angiotensin-converting enzyme (ACE) inhibitors for people with stable angina and diabetes. Offer or continue ACE inhibitors for other conditions, in line with relevant NICE guidance
• Offer statin treatment in line with Lipid modification (NICE clinical guideline 67)
• Offer treatment for high blood pressure in line with Hypertension (NICE clinical guideline 127).

Dietary Supplements

• Do not offer vitamin or fish oil supplements to treat stable angina. Inform people that there is no evidence that they help stable angina.

Anti-anginal Drug Treatment

General Recommendations

• Offer people optimal drug treatment for the initial management of stable angina. Optimal drug treatment consists of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease
• Advise people that the aim of anti-anginal drug treatment is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke
• Discuss how side-effects of drug treatment might affect the person's daily activities and explain why it is important to take drug treatment regularly
• Patients differ in the type and amount of information they need and want. Therefore the provision of information should be individualised and is likely to include, but not be limited to:
  • what the medicine is
  • how the medicine is likely to affect their condition (that is, its benefits)
  • likely or significant adverse effects and what to do if they think they are experiencing them
  • how to use the medicine
  • what to do if they miss a dose
  • whether further courses of the medicine will be needed after the first prescription
  • how to get further supplies of medicines (This recommendation is from Medicines adherence [NICE clinical guideline 76])
• Review the person's response to treatment, including any side-effects, 2–4 weeks after starting or changing drug treatment
• Titrate the drug dosage against the person's symptoms up to the maximum tolerable dosage.

Drugs for Treating Stable Angina

• Offer either a beta-blocker or a calcium-channel blocker as first-line treatment for stable angina. Decide which drug to use based on comorbidities, contraindications and the person's preference
• If the person cannot tolerate the beta-blocker or calcium-channel blocker, consider switching to the other option (calcium-channel blocker or beta-blocker)
• If the person's symptoms are not satisfactorily controlled on a beta-blocker or a calcium-channel blocker, consider either switching to the other option or using a combination of the two^[A]
• Do not routinely offer anti-anginal drugs other than beta-blockers or calcium-channel blockers as first-line treatment for stable angina
• If the person cannot tolerate beta-blockers and calcium-channel blockers or both are contraindicated, consider monotherapy with one of the following drugs:
  • a long-acting nitrate or
  • ivabradine or
  • nicorandil or
  • ranolazine
    
    Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs^[B]
• For people on beta-blocker or calcium-channel blocker monotherapy whose symptoms are not controlled and the other option (calcium-channel blocker or beta-blocker) is contraindicated or not tolerated, consider one of the following as an additional drug:
  • a long-acting nitrate or
  • ivabradine^[C] or
  • nicorandil or
  • ranolazine
    
    Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs^[B]
• Do not offer a third anti-anginal drug to people whose stable angina is controlled with two anti-anginal drugs
• Consider adding a third anti-anginal drug only when:
  • the person's symptoms are not satisfactorily controlled with two anti-anginal drugs and
  • the person is waiting for revascularisation or revascularisation is not considered appropriate or acceptable.
    
    Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs.

Investigation and Revascularisation

People With Stable Angina Whose Symptoms Are Not Satisfactorily Controlled With Optimal Medical Treatment

• Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment.

People With Stable Angina Whose Symptoms Are Satisfactorily Controlled With Optimal Medical Treatment

• Discuss the following with people whose symptoms are satisfactorily controlled with optimal medical treatment:
  • their prognosis without further investigation
  • the likelihood of having left main stem disease or proximal three-vessel disease
  • the availability of CABG to improve the prognosis in a subgroup of people with left main stem or proximal three-vessel disease
  • the process and risks of investigation
  • the benefits and risks of CABG, including the potential survival gain.

Pain Interventions

• Do not offer the following interventions to manage stable angina:
  • transcutaneous electrical nerve stimulation (TENS)
  • enhanced external counterpulsation (EECP)
  • acupuncture.

Stable Angina that Has Not Responded to Treatment

• Offer people whose stable angina has not responded to drug treatment and/or revascularisation comprehensive re-evaluation and advice, which may include:
  • exploring the person's understanding of their condition
  • exploring the impact of symptoms on the person's quality of life
  • reviewing the diagnosis and considering non-ischaemic causes of pain
  • reviewing drug treatment and considering future drug treatment and revascularisation options
  • acknowledging the limitations of future treatment
  • explaining how the person can manage the pain themselves
  • specific attention to the role of psychological factors in pain
  • development of skills to modify cognitions and behaviours associated with pain.

Footnotes

[A] When combining a calcium-channel blocker with a beta-blocker, use a dihydropyridine calcium-channel blocker, for example, slow release nifedipine, amlodipine or felodipine.

[B] Since this guidance was produced, the Medicines and Healthcare products Regulatory Agency (MHRA) have published new advice about safety concerns related to ivabradine (June 2014 and December 2014) and nicorandil (January 2016).

[C] When combining ivabradine with a calcium-channel blocker, use a dihydropyridine calcium-channel blocker, for example, slow release nifedipine, amlodipine, or felodipine.