What is Angina pectoris?

chest pain or pressure, usually caused by transient insufficient blood flow to the heart muscle

What medication should all patients with stable angina receive?

• aspirin and a statin in the absence of any contraindication
• sublingual glyceryl trinitrate to abort angina attacks
• a beta-blocker or a calcium channel blocker first-line based on 'comorbidities, contraindications and the person's preference'

if a calcium channel blocker is used as monotherapy for angina which should be used?

a rate-limiting one such as verapamil or diltiazem should be used

if a calcium channel blocker is used in combination with a beta-blocker for angina which should be used?

a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine)

When can a third agent be considered in stable angina?

if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

In stable angina if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then what can be added?

One of:

• a long-acting nitrate
• ivabradine
• nicorandil
• ranolazine

Nitrate tolerance

• many patients who take nitrates develop tolerance and experience reduced efficacy
• NICE advises that patients who take standard-release isosorbide mononitrate should use {{c1::an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance}}
• this effect is not seen in patients who take {{c2::once-daily modified-release isosorbide mononitrate}}