Angina Pectoris

INTRODUCTION

This is an oppressive retrosternal discomfort that radiates to the arms, jaw and throat. If unstable, it is considered a pre-myocardial infarct.

MANAGEMENT OF STABLE ANGINA

• Attend to any risk factors, e.g. obesity, smoking, hypertension, diabetes, blood lipids

• If inactive, take on an activity such as walking for 20 mins a day

• Regular exercise to the threshold of angina

• Relaxation program

• Avoid precipitating factors

• Don’t excessively restrict lifestyle

Medical treatment

The acute attack

• Glyceryl trinitrate 600 mcg tab or 300 mcg (½ tab) SL or

• Glyceryl trinitrate 400 mcg SL spray: 1–2 sprays; rpt after 5 mins if pain persists (max. 3 doses) or

• Isosorbide dinitrate 5 mg SL; rpt every 5 mins (max. 3 doses) or

• Nifedipine 5 mg capsule (suck or chew), if intolerant of nitrates or

• Aspirin 150 mg (o)

Advise that if no relief after 2–3 tabs, get medical advice.

Avoid nitrates if s. phosphodiesterase inhibitors used for ED in past 1–5 d.

Mild stable angina Angina that is predictable, precipitated by more stressful activities and relieved rapidly

• Aspirin 150 mg (o)/d (use clopidogrel 75 mg (o)/d if intolerant)

• Glyceryl trinitrate (SL or spray) prn (use early)

• Consider a beta blocker or long-acting nitrate or nicorandil

Moderate stable angina Regular predictable attacks precipitated by moderate exertion

• As above plus

• Beta blocker, e.g. atenolol 25–100 mg (o) once/d or metoprolol 25–100 mg (o) once/d, starting with the lowest dose and increasing as necessary

• Glyceryl trinitrate (ointment or patches) daily (12–16 h only) or isosorbide mononitrate 60 mg (o) SR tablets mane (12-h span)

If not controlled Add a dihydropyridine calcium-channel blocker:

• nifedipine controlled release 30–60 mg (o)/d or

• amlodipine 2.5–10 mg (o) once/d

If beta blocker contraindicated, use:

• diltiazem SR 90 mg (o) bd (max. 240 mg/d) or CR 180–360 mg (o)/d, or

• nicorandil 5 mg (o) bd, ↑ to 10–20 mg bd after 1 wk

Persistent or refractory angina Consider ivabradine but patients require specialist evaluation for suitability for a corrective procedure (see below).

Unstable angina Hospitalise for stabilisation and further evaluation. The objectives are to optimise therapy, give IV trinitrate and heparin and consider coronary angiography with a view to a corrective procedure such as CABG surgery or percutaneous transluminal angioplasty stenting.