Angina is pain or constricting discomfort that typically occurs in the front of the chest (but may radiate to the neck, shoulders, jaw or arms) and is brought on by physical exertion or emotional stress.

Diagnose stable angina according to NICE guidance on chest pain of recent onset (CG95).

Patients with chest pain of recent onset should be referred to the rapid access chest pain clinic for assessment. Assessment will include appropriate investigation to confirm diagnosis, provide risk stratification and guide appropriate revascularisation for symptomatic or prognostic disease.

Patients should be considered for the same treatment regardless of age (taking co-morbidity into account).

Symptomatic relief

Short-acting nitrate

• Glyceryl trinitrate
• For preventing and treating episodes of angina, immediate short-term relief
• See 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

First-line treatment

Beta-blocker

• Atenolol, Bisoprolol, Metoprolol
• See 2.4 Beta-adrenoceptor blocking drugs

OR

Calcium channel blocker

• Diltiazem modified release
• See 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

If beta blockers and calcium channel blockers are contraindicated or not tolerated

Consider monotherapy with either:

• Isosorbide mononitrate long-acting
• Nicorandil
• Ivabradine

With addition of:

• Ranolazine (licensed for add-on only)
• See 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

Symptoms not controlled or treatment not tolerated

Patient on a beta blocker

Add or change to amlodipine or nifedipine MR (Adalat LA®)

Patient on first-line calcium channel blocker (diltiazem MR)

Change calcium channel blocker to amlodipine or nifedipine MR (Adalat LA®)

Patient on beta blocker or calcium channel blocker monotherapy and the other option (calcium channel blocker or beta blocker) is contraindicated or not tolerated

Consider one of the following as an additional drug:

• Isosorbide mononitrate long-acting
• Nicorandil
• Ivabradine
• Ranolazine (licensed for add-on only)
• See 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

Symptoms still not controlled or treatment not tolerated

Consider specialist referral

If symptoms are not satisfactorily controlled consider adding or change to:

• Isosorbide mononitrate long-acting
• Nicorandil
• Ivabradine
• Ranolazine (licensed for add-on only). Ranolazine should only be used as a last line option after consideration and / or trial of other therapies
• See 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

Only add a third drug if:

• symptoms are NOT controlled with two antianginal drugs, AND
• the person is waiting for revascularisation or revascularisation is not appropriate or acceptable.

Notes

1. Nicorandil has similar efficacy to other anti-anginal drugs in controlling symptoms; it may produce additional symptomatic benefit in combination with other antianginal drugs (unlicensed indication).
2. Ivabradine is indicated in adults unable to tolerate or with a contra-indication to the use of beta-blockers or in combination with beta-blockers in patients inadequately controlled with an optimal beta-blocker dose and whose heart rate is greater than 60 bpm. However, in practice beta-blockers and ivabradine are rarely used in combination.
3. Ranolazine is licensed as add-on therapy for the symptomatic treatment of patients with stable angina pectoris who are inadequately controlled or intolerant to first-line anti anginal therapies (such as beta-blockers and/or calcium antagonists).
4. When combining a calcium-channel blocker and a beta-blocker it is recommended that a dihydropyridine CCB (amlodipine or nifedipine) is used.
5. When adding nicorandil to CCB or B-blocker this is an unlicensed indication.
6. When adding ivabradine to a CCB then the CCB should be a dihydropyridine CCB (amlodipine or felodipine).

1. Offer a statin in line with formulary guidance on lipid modification.
2. Offer treatment for high blood pressure in line with formulary guidance on hypertension.
3. Consider aspirin 75mg, taking into account the risk of bleeding and co-morbidities
4. Consider angiotensin converting enzyme (ACE) inhibitors in people with stable angina and type 2 diabetes in line with NICE guidance on type 2 diabetes (CG87).
5. Offer or continue ACE inhibitors for other conditions in line with relevant NICE guidance.
6. If symptoms are not satisfactorily controlled with optimal drug treatment (two anti-anginal drugs plus secondary prevention drugs), consider revascularisation — either CABG or PCI. See NICE CG126 for more information on CABG and PCI and associated investigations e.g. coronary angiography (see below for more information on revascularisation).
7. CABG is also an option for people whose symptoms are satisfactorily controlled on optimal drug treatment to improve prognosis in a sub group of people with left main stem or proximal three-vessel disease.

Local cardiologists advise that:

All patients with angina, controlled or otherwise, who, considering co-morbidity, are sufficiently robust so as to be considered for revascularisation and who after discussion with their doctor wish to be referred, should be referred to a cardiologist at least once for risk stratification and consideration of revascularisation. This will normally be at diagnosis. Those who are not considered fit enough for revascularisation could reasonably be managed symptomatically.