The initial management of people diagnosed with stable angina should be optimal drug treatment rather than revascularisation procedures, says the National Institute for Health and Clinical Excellence (NICE).
People who are diagnosed with stable angina should initially be offered optimal drug treatment to provide immediate symptom relief and prevent future attacks, and this should include one or two anti-anginal drugs as necessary, says new NICE guidance. Additional drug treatments should also be offered for secondary prevention treatment, which aims to lower the risk of having a heart attack or stroke, it adds.
If a person does not respond to drug treatment, they should offered one of two techniques for revascularisation – coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) – to help increase the flow of blood to the heart and to relieve symptoms.
The guidance says patients should be offered glyceryl trinitrate, a short-acting nitrate, for preventing and treating episodes of angina and, for the initial management of stable angina, either a beta blocker or a calcium channel blocker as first-line treatment. If the person cannot tolerate beta blockers and calcium channel blockers or both are contraindicated, then monotherapy with either a long-acting nitrate, Servier’s Procoralan (ivabradine), Sanofi’s Ikorel (nicorandil) or Gilead Sciences’ Ranexa (ranolaxine) should considered.
People whose stable angina is controlled with two anti-anginal drugs should not be offered a third, it adds.
For secondary prevention of cardiovascular disease, consideration should be given to aspirin 75mg daily for people with stable angina – taking into account the risk of bleeding and co-morbidities – andangiotensin-converting enzyme (ACE) inhibitors for people who have stable angina and diabetes. People should also be offered statin treatment – in line with Lipid modification: NICE clinical guideline 67 – and treatment for high blood pressure – in line with Hypertension: NICE clinical guideline 34, it adds.
Adam Timmis, professor of clinical cardiology at The London Chest Hospital, said that the main impact of the guideline will be its emphasis on “optimal medical treatment” as the initial treatment strategy for all patients with angina, with PCI and CABG reserved principally for patients who remain symptomatic.
“No longer will it be acceptable to undertake these revascularisation procedures in patients not receiving anti-anginal and secondary prevention treatment as detailed in this guideline,” said Prof Timmis.
Current estimates suggest that almost 2 million people in England now have or have had angina, including around 8% of men and 3% of women aged 55-64. These figures rise to 14% and 8% respectively for men and woman aged 65-74.
Angina “does not appear to be declining in incidence,” unlike other manifestations of coronary artery disease, commented Dr Fergus Macbeth, director of NICE’s clinical practice centre. “This guideline provides very clear recommendations, based on the most up-to-date evidence, about what treatments, including revascularisation, are most effective at reducing risk and improving outcomes for people with stable angina,” he added.
