Angina
The pathways in this section are intended as a guide for initiation of the pharmacological management of Angina according to the individual patient assessment of symptoms.
NICE CG126 Stable angina: management SIGN 151 Management of stable angina
Sublingually, 400microgram-800microgram repeated as required.
Sublingually, 500microgram-1mg repeated as required.
Prescribing Notes:
- Glyceryl trinitrate (GTN) intravenous injection may be given when sublingual GTN is ineffective in patients with chest pain due to myocardial infarction or severe ischaemia, and in treatment of acute left ventricular failure.
History Notes
16/02/2022
East Region Formulary content agreed.
The first step in angina management is to control the heart rate, aiming for resting heart rate around 60bpm or below. If heart rate already <= 60 go to step 2.
Beta-blockers should be avoided in patients with a history of asthma.
Usual starting dose is 5 mg once daily. Reasonable to start at lower dose and titrate up depending on resting HR and BP (especially in elderly). Usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.
Usual starting dose is 5 mg once daily. Reasonable to start at lower dose and titrate up depending on resting HR and BP (especially in elderly). Usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.
Usual starting dose is 5 mg once daily. Reasonable to start at lower dose and titrate up depending on resting HR and BP (especially in elderly). Usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.
Usual starting dose is 5 mg once daily. Reasonable to start at lower dose and titrate up depending on resting HR and BP (especially in elderly). Usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.
Usual starting dose is 5 mg once daily. Reasonable to start at lower dose and titrate up depending on resting HR and BP (especially in elderly). Usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.
Usual starting dose is 5 mg once daily. Reasonable to start at lower dose and titrate up depending on resting HR and BP (especially in elderly). Usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.
Diltiazem or verapamil preferred to bisoprolol if asthma is present.
Once daily dosing is preferred. See BNF for brand specific information.
Once daily dosing is preferred. See BNF for brand specific information.
Once daily dosing is preferred. See BNF for brand specific information.
Once daily dosing is preferred. See BNF for brand specific information.
Once daily dosing is preferred. See BNF for brand specific information.
Once daily dosing is preferred. See BNF for brand specific information.
See BNF for dosing and frequency. Only for use in initiation of treatment with diltiazem when required.
Dose according to brand. See BNF.
Dose according to brand. See BNF.
If heart rate is reduced, consider isosorbide mononitrate as first line treatment.
If the patient's symptoms are not satisfactorily controlled on single agent treatment from step 1, then consider addition of isosorbide mononitrate or adding amlodipine (non rate-limiting CCB) to bisoprolol. Amlodipine is an option if CCB not already prescribed and if BP remains elevated.
20–40mg twice daily (10mg twice daily in those who have not previously received nitrates); up to 120mg daily in divided doses if required.
20–40mg twice daily (10mg twice daily in those who have not previously received nitrates); up to 120mg daily in divided doses if required.
20–40mg twice daily (10mg twice daily in those who have not previously received nitrates); up to 120mg daily in divided doses if required.
Dose according to brand. See BNF.
Dose according to brand. See BNF.
Initially 5mg once daily; max 10mg once daily.
Initially 5mg once daily; max 10mg once daily.
If patient cannot tolerate beta blockers and calcium channel blockers or both are contraindicated, consider nicorandil or ivabradine as monotherapy. Do not combine ivabradine with a rate-limiting CCB - diltiazem or verapamil - as severe bradycardia and heart failure can occur.
Initially 5–10 mg twice daily, then increased if tolerated to 40 mg twice daily; usual dose 10–20 mg twice daily, use lower initial dose regimen if patient susceptible to headache.
Initially 5–10 mg twice daily, then increased if tolerated to 40 mg twice daily; usual dose 10–20 mg twice daily, use lower initial dose regimen if patient susceptible to headache.
Angina,
Adult 18–74 years: Initially 2.5–5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily.
Adult 75 years and over: Initially 2.5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily
Angina,
Adult 18–74 years: Initially 2.5–5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily.
Adult 75 years and over: Initially 2.5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily
If angina remains uncontrolled consider addition of nicorandil or ivabradine (an option if BP low and rate not controlled). Do not combine ivabradine with a rate-limiting CCB - diltiazem or verapamil - as severe bradycardia and heart failure can occur. Amlodipine is an option if CCB not already prescribed and if BP remains elevated. Consider also as alternative treatment options if other options are not tolerated/contraindicated.
Initially 5–10 mg twice daily, then increased if tolerated to 40 mg twice daily; usual dose 10–20 mg twice daily, use lower initial dose regimen if patient susceptible to headache.
Initially 5–10 mg twice daily, then increased if tolerated to 40 mg twice daily; usual dose 10–20 mg twice daily, use lower initial dose regimen if patient susceptible to headache.
Angina,
Adult 18–74 years: Initially 2.5–5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily.
Adult 75 years and over: Initially 2.5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily
Angina,
Adult 18–74 years: Initially 2.5–5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily.
Adult 75 years and over: Initially 2.5 mg twice daily for 3–4 weeks, then increased if necessary up to 7.5 mg twice daily, dose to be increased gradually; reduced if not tolerated to 2.5–5 mg twice daily
Initially 5mg once daily; max 10mg once daily.
Initially 5mg once daily; max 10mg once daily.
Prescribing Notes:
- To reduce the risk of nitrate tolerance, isosorbide mononitrate immediate release tablets should be given twice daily 6-8 hours apart.
- Isosorbide mononitrate modified-release tablets are initiated at dose of 25mg or 30mg (half of a 60mg tablet).
- Beta-blockers may cause bronchospasm; avoid in patients suffering asthma. If a beta-blocker is required a cardioselective beta-blocker should be selected, initiated at a low dose and the patient closely monitored.
- Diltiazem and verapamil are first choice calcium-channel blockers for angina if a beta-blocker cannot be used.
- Diltiazem should be used with caution if given with beta blockers due to risk of bradycardia.
- Modified release diltiazem should be prescribed by brand name due to differences in bioavailability between brands. Once daily preparations should be chosen for patient compliance.
- Verapamil is used for angina, hypertension and arrhythmia; it reduces cardiac output, slows the heart rate and may affect atrioventricular conduction.
- Verapamil should not be used with beta-blockers.
- Nicorandil is used when other anti-anginal drugs are insufficient; it has similar efficacy to other anti-anginal drugs in controlling symptoms but there is little evidence regarding its efficacy in combination with other anti-anginal drugs. Unlike the nitrates, patients do not develop tolerance with nicorandil. 5mg twice daily is an appropriate starting dose if patient is susceptible to headache.
- Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative. See Nicorandil MHRA advice.
- Ivabradine is approved for use, on the initiation of a specialist, for chronic stable angina in patients with normal sinus rhythm for whom heart rate control is desirable and who have a contra-indication or intolerance for beta-blockers and rate-limiting calcium-channel blockers.
- Ivabradine is associated with an increased risk of bradycardia and atrial fibrillation. It should only be used when pre-treatment resting heart rate is above 70bpm in sinus rhythm, and should not be used in conjunction with verapamil or diltiazem. Reduce the dose or discontinue ivabradine if resting HR falls below 50bpm. Discontinue treatment if no improvement in symptoms within 3 months. Avoid ivabradine in patients with a history of AF. See Ivabradine MHRA advice.
- In patients with angina or a previous myocardial infarction, a sudden withdrawal of a beta-blocker may cause an exacerbation of symptoms and therefore gradual reduction of dose is preferable when beta-blockers are to be stopped.
History Notes
31/10/2024
Updates to prescribing information, ERFC October 24.
16/02/2022
East Region Formulary content agreed.
Ensure the patient is taking the maximal licensed or tolerated dose. Refer to cardiology specialist.
History Notes
16/02/2022
East Region Formulary content agreed.