The NICE Centre for Clinical Practice is an NHS Evidence accredited provider
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19 August 2011
New NICE guidance on the management of stable angina (clinical guideline [CG] 126) has been published. This covers patient information and advice, optimal drug treatment and revascularisation for people with a diagnosis of stable angina. The diagnosis of stable angina is covered in existing NICE guidance on chest pain of recent onset (CG95).
Action
Health care professionals, managers and commissioners should familiarise themselves with this guideline and collaborate to develop local care pathways that promote optimal management of people with stable angina. The guideline recommends the use of a short-acting nitrate and optimal drug treatment — i.e. one or two anti-anginal drugs as necessary (usually beta blocker and/or calcium channel blocker – see below), plus treatments for the secondary prevention of cardiovascular disease (e.g. statin, antihypertensives). Revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) should usually be considered only if symptoms are not satisfactorily controlled with optimal drug treatment. CABG may be an option for certain patients with multivessel disease who are satisfactorily controlled on optimal drug treatment.
Key points on management of stable angina (CG126):
- Diagnose stable angina according to NICE guidance on chest pain of recent onset (CG95).
- Offer advice and provide information and support — e.g. lifestyle advice, factors that may provoke angina, risks and benefits of their treatment, when to seek professional help.
- Offer a short-acting nitrate for preventing and treating episodes of angina and advise on the correct administration, including possible side effects.
- Offer one or two anti-anginal drugs as necessary — either a beta blocker or calcium channel blocker first-line. Choice should be based on comorbidities, contraindications and patient preference. If symptoms are not satisfactorily controlled on one anti-anginal drug, consider either switching to the other option, or use both in combination. If using in combination, a dihydropyridine calcium channel blocker (e.g. slow release nifedipine, amlodipine or felodipine) should be combined with a beta blocker. Do not routinely offer other anti-anginal drugs first-line.
- Review response to treatment, including side-effects, two to four weeks after starting or changing drug treatment. Titrate the dosage against the person’s symptoms, up to the maximum tolerated dose.
- Other anti-anginals — long-acting nitrate, or ivabradine▼, or nicorandil, or ranolazine▼ may be considered in certain circumstances (e.g. if beta blockers and/or calcium channel blockers are contraindicated or not tolerated). Choice should be based on comorbidities, contraindications, patient preference and drug costs.
- A third anti-anginal drug should be considered only when:
- two anti-anginal drugs do not satisfactorily control symptoms, and
- the person is awaiting revascularisation (see below) or revascularisation is not appropriate or acceptable
- Offer a statin (see NICE guidance on lipid modification [CG67]).
- Offer treatment for high blood pressure (see NICE guidance on hypertension [CG34]).
- Consider aspirin 75mg, taking into account the risk of bleeding and co-morbidities.
- Consider angiotensin converting enzyme (ACE) inhibitors in people with stable angina and type 2 diabetes (see NICE guidance on type 2 diabetes [CG87]).
- Offer or continue ACE inhibitors for other conditions in line with relevant NICE guidance.
- 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.
- 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.
More information
The recommendations in this guideline (CG126) relate only to people with a diagnosis of stable angina. Coronary artery disease can also present as acute coronary syndromes (ACS), such as unstable angina or myocardial infarction (MI). As in stable angina, these patients should be diagnosed according to NICE guidance on chest pain of recent onset (CG95), but managed according to NICE guidance on unstable angina and NSTEMI (CG94) and secondary prevention of MI (CG48). This new guideline on stable angina partially updates NICE technology appraisal 73 on myocardial perfusion scintigraphy for the diagnosis and management of angina and MI.
Further information on can be found on NHS Evidence and in the cardiovascular e-learning section of NPC.
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