Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris

Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris
DIAGNOSIS
Angina is the commonest symptom of CHD, with a prevalence of 2-4% in the UK adult population It is essentially a set of symptoms resulting
from cardiac ischaemia, the most common of which is intense but diffuse, crushing retrosternal pain, normally precipitated by exercise It can also
be brought on by eating a large meal, going out in the cold or emotional responses
Stable angina refers to a patient whose symptoms are unchanging or only progressing slowly. Patients with rapidly progressive, severe or
unstable symptoms should be referred as an emergency to A&E; they are NOT covered by this guideline
A working diagnosis of angina is made on the clinical history, especially the nature of the pain. However, there are a number of differential causes
of this kind of pain, which may on occasion be difficult to distinguish.
The initial assessment process outlined below will aid this discrimination

ASSESSMENT
1. CLINICAL HISTORY

Nature of the pain

Precipitants
Stability of symptoms
Smoking history
Exercise grading
Occupation
Age / sex
Dietary assessment
Alcohol intake
Current medication (including OTC and illicit)
Family history
Co-morbidities

2. EXAMINATION

Weight / height and BMI

Blood pressure
Pulse rate
Presence / absence of murmurs (especially aortic stenosis)
Signs of hyperlipidaemia
Evidence of peripheral vascular disease and/or carotid bruits
Signs of thyroid disease

3. INVESTIGATIONS

Full blood count (to exclude anaemia)

Fasting plasma glucose (to exclude diabetes)
Fasting lipid profile
Thyroid function
12 Lead ECG (an abnormal ECG identifies a higher risk population)
Biochemistry profile (renal function)

Calculation of 10 year CHD risk is NOT possible in angina patients; angina is considered to indicate existing CHD and thus patients in this group
are secondary prevention.

Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris
INITIAL MANAGEMENT

Explain the condition to the patient and give initial advice

Aim to modify risk factors for CHD as per medication review section
Prescribe antiplatelet prophylaxis unless contraindicated as per Medication review section.
Prescribe short acting glyceryl trinitrate for acute symptom relief and situational prophylaxis, with appropriate instructions on how to take the
treatment
Test the effects of beta blocker and titrate to full dose, in case of beta blocker intolerance or poor efficacy attempt montherapy with a calcium
channel blocker, long acting nitrate, nicorandil or ivabradine
If the effects of beta blocker monotherapy are insufficient, add a dihydropyradine calcium channel blocker
In case of beta blocker intolerance substitute with ivabradine
If CCB monotherapy or combination therapy is unsuccessful, substitute the long CCB with a long acting nitrate or nicorandil.
Consider triple therapy only if optimal two drug regimens are insufficient
Consider occupational factors: patients holding LGV and PCV licences should contact the DVLA and stop driving these vehicles. Normal motorists
may continue to drive but should inform their insurance company. Patients who operate heavy machinery may also be affected.
Review existing medication for exacerbating drugs. If ibuprofen prescribed, select alternative NSAID eg diclofenac (ibuprofen may increase CV risk
in these patients)
At this point, referral to the Rapid Access Chest Pain Clinic is indicated for:
All new patients (for exercise stress testing to confirm diagnosis)
Those where diagnosis is in doubt
Refer to cardiology for patients unable to undergo exercise stress testing, eg patients:
Who are physically incapable of taking the test
Who may have aortic stenosis or cardiomyopathy
Where the results of the test would not influence the management of the patient (e.g. if terminally ill)

REFERRAL
The following are those suggested by PRODIGY/SIGN

1. URGENT REFERRAL
Pain on minimal exertion
Pain at rest (which may occur at night)
Angina which appears to be progressing rapidly despite increasing medical treatment

2. EARLY REFERRAL
People who have had a previous MI, coronary artery bypass graft (CABG) or percutanous transluminal coronary angioplasty (PCTA) and develop
angina
People who appear to have evidence of a previous MI or other significant abnormality
People who fail to respond to medical treatment
People who have an ejection systolic murmur, suggesting aortic stenosis

3. ROUTINE REFERRAL

To confirm or refute a diagnosis with uncertain or atypical symptoms

To advise on the management of an individual, particularly where the person has not responded to treatment or risk factor modification
The presence of a number of risk factors or a strong family history
Patient preference for referral
Problems with employment, life insurance, or unacceptable interference with lifestyle
Significant co-morbidity

Treatment should not be delayed whilst awaiting referral.

Not all patients may wish to be referred.
Referral can also be to Tier 2 cardiology clinic if available.
Not all patients with angina need to be referred. The QOF measures the percentage of patients with newly diagnosed angina (diagnosed after April
2003) who are referred for exercise testing and/or specialist assessment, but it is important to note that there are exclusions and for full details of
these please refer to section 3.30 of the new General Medical Services Contract.
Exclusion include:
Some patients may not wish to be referred
Some patients may have a more significant condition e.g. general frailty, advanced years or major co-morbidity, affecting their quality of life and
prognosis

Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris
MANAGEMENT OF RISK FACTORS
1. SMOKING

Advise about the risks

Advise to stop smoking
Refer to or make aware of the smoking cessation service
Prescribe pre-quit NRT / bupropion/ veranicline/ nortryptyline as appropriate (see NICE guidance)

2. DIET / ALCOHOL

Increase consumption of oil-rich fish

Increase consumption of fruit, vegetables, cereals and foods low in saturated fats (Mediterranean diet)
Decrease sugar and salt consumption
Encourage to limit alcohol consumption to 3 units per day (men) / 2 units per day (women)

3. PHYSICAL ACTIVITY
Encourage to increase level of aerobic exercise to the limits imposed by their condition
Aim for 20-30 minutes of exercise 3-5 times per week
Refer to exercise on prescription where appropriate

4. WEIGHT / OBESITY
Encourage patient to lose weight to achieve BMI < 25

5. MANAGE CO-MORBIDITIES
Optimal diabetes management (aim for HbA1c < 7%)
Monitor blood pressure; where appropriate treat to target
Where CHD confirmed, prescribe a statin to reduce to target of total cholesterol/ HDL ratio of 3.5.
NB: For many patients who do not reach this target concordance to medications is often the reason
All these interventions should be recorded using appropriate codes

CLASSIFICATION OF ANGINA SEVERITY ACCORDING TO THE CANADIAN CARDIOVASCULAR SOCIETY

CLASS LEVEL OF SYMPTOMS
Class I: Ordinary activity does not cause angina

Angina with strenuous or rapid or prolonged exertion only

Class II: Slight limitation of ordinary activity

Angina on walking or climbing stairs rapidly, walking uphill or exertion after meals, in cold weather, when under emotional stress, or
only during the first few hours after awakening

Class III: Marked limitation of ordinary physical activity

Angina on walking one or two blocks on the level or one flight of stairs at a normal pace under normal conditions

Class IV: Inability to carry out any physical activity without discomfort or angina at rest
Equivalent to 100200 m.

Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris
REFERRAL PATHWAY
Patients presents with
existing but worsening
angina

Patient presents with

recent onset of symptoms

GP assessment. History inc PMH and Meds and exam

- risk factors
- Investigations
o FBC
o Biochemical Profile
o Fasting Lipid Profile & blood glucose
o Pulse & BP
o 12 lead ECG

Referral to
Tier 2

Pain on minimal
exertion
-Unstable angina

Admit

Electronic referral to Rapid Access

Chest Pain Clinic
(Consider nGMS exclusion criteria)

Referral to
cardiologist

Cardiology Opinion refer to Rapid

Access Chest Pain Pathway

Functional
Assessment

In-patients suspected
of having angina

Angiography

ANGINA
Cardiac Rehabilitation & Optimise Medical management (European
Society of Cardiology Algorithm for Stable Angina)

Continue Medical
management

PTCA

Further Cardiology Review

Referral back to GP

At-least annual GP Review

Put patient on GP register
Give patient heart health record
Medication Review
Risk factor assessment and active management
Symptom assessment and active management

CABG

Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris

Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris
GENERAL PRACTICE REVIEW AFTER REFERRAL BACK TO GP:
RICK FACTOR ASSESSMENT AND ACTIVE MANAGEMENT:
1. SMOKING

Advise about the risks

Advise to stop smoking
Refer to or make aware of the smoking cessation service
Prescribe NRT / bupropion as appropriate (see NICE guidance)

2. DIET / ALCOHOL

Increase consumption of oil-rich fish

Increase consumption of fruit, vegetables, cereals and foods low in saturated fats (Mediterranean diet)
Decrease sugar and salt consumption
Encourage to limit alcohol consumption to 3 units per day (men) / 2 units per day (women)

3. PHYSICAL ACTIVITY
Encourage to increase level of aerobic exercise to the limits imposed by their condition
Aim for 20-30 minutes of exercise 3-5 times per week
Refer to exercise on prescription where appropriate

4. WEIGHT / OBESITY
Encourage patient to lose weight to achieve BMI < 25

5. MANAGE CO-MORBIDITIES
Manage diabetes (aim for HbA1c < 7%) aim for optimal diabetes management
Monitor blood pressure; where appropriate treat to target
Where CHD confirmed, prescribe a statin to reduce to target
All these interventions should be recorded using appropriate codes

MEDICATION REVIEW:
RECOMMENDATIONS FOR PHARMACOLOGICAL THERAPY TO IMPROVE PROGNOSIS IN PATIENTS WITH STABLE ANGINA
Aspirin 75 mg daily in all patients without specific contraindications (ie active GI bleeding, aspirin allergy or previous aspirin intolerance). Consider
Clopidogrel as an alternative antiplatelet agent in patients with stable angina who cannot take aspirin eg Aspirin allergic.
Statin therapy for all patients with coronary disease.
ACE-inhibitor therapy in patients with coincident indications for ACE-inhibition, such as hypertension, heart failure, LV dysfunction, prior MI with LV
dysfunction, or diabetes
Oral beta blocker therapy in patients post-MI or with heart failure
ACE-inhibitor therapy in all patients with angina and proven coronary disease.

RECOMMENDATIONS FOR PHARMACOLOGICAL THERAPY TO IMPROVE SYMPTOMS AND/OR REDUCE ISCHAEMIA IN PATIENTS
WITH STABLE ANGINA.
PROVIDE Short-acting nitroglycerin for acute symptom relief and situational prophylaxis, with appropriate instructions on how to use the treatment
Test the effects of a beta-1 blocker, and titrate to full dose; consider the need for 24 h protection against ischaemia
In case of beta-blocker intolerance or poor efficacy attempt monotherapy with a calcium channel blocker, long acting nitrate, nicorandil or ivabradine
If the effects of beta-blocker monotherapy are insufficient, add a dihydropyridine calcium channel blocker
In case of beta-blocker intolerance substitute ivabradine
If CCB monotherapy or combination therapy (CCB with beta-blocker) is unsuccessful, substitute the CCB with a long-acting nitrate or nicorandil.
Be careful to avoid nitrate tolerance
Metabolic agents may be used where available as add on therapy, or as substitution therapy when conventional drugs are not tolerated
Consider triple therapy only if optimal two drug regimens are insufficient, and evaluate the effects of additional drugs carefully. Patients whose
symptoms are poorly controlled on double therapy should be assessed for suitability for revascularization, as should those who express a strong
preference for revascularization rather than pharmacological therapy. The ongoing need for medication to improve prognosis irrespective of
revascularization status, and the balance of risk and benefit on an individual basis, should be explained in detail.
If inadequate symptom control after 3 months consider PCI or CABG and refer back to cardiology.

Anti-anginal drug treatment should be tailored to the needs of the individual patient, and should be monitored individually.

Primary Care Guidelines for the Treatment

of Chronic Stable Angina Pectoris
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Department of Health. Stable Angina (Chapter 4) National Service Framework for Coronary Heart Disease. London: DoH, 2000
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de Bono D, et al. Investigation and management of stable angina: revised guidelines 1998. Heart, May 1999; 81: 546-555
Anon. Stable angina. PRODIGY Guidelines
Anon. Secondary prevention of ischaemic events. Clinical Evidence,Volume 7, BMJ 2002
North of England Stable Angina Guideline Development Group. North of England evidence based guidelines development project: summary
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Consumers Association. Too many beta-blockers. Drug Ther Bull, 1996; 34: 49-52
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Medicines Resource Centre. Nicorandil, a novel antianginal drug. MeReC Bulletin ,1995; 6: 24
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Anon. Nicorandil in stable angina. MeReC Extra, Number 5, June 2002
Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European
Society of Cardiology. European Heart Journal (2006) 27, 13411381
R J P Lewin, G Furze, J Robinson, K Griffith, S Wiseman, M Pye and R Boyle. A randomised controlled trial of a self-management plan for
patients with newly diagnosed angina. British Journal of General Practice, March 2002

DEVELOPED FOR THE GREATER MANCHESTER AND CHESHIRE CARDIAC NETWORK BY THE
PRACTITIONERS WITH SPECIALIST INTEREST IN CARDIOLOGY LEADING LIGHTS GROUP.
The Practitioners with Specialist Interest in Cardiology Leading Lights Group:
Dr Ivan Benett Manchester P.C.T.
Mrs Paula Bithell Rochdale Infirmary
Mr Richard Carty Fairfield General Hospital
Dr Eddie Thornton Chan Tameside and Glossop P.C.T.
Dr Sumit Guhathakurta Bolton P.C.T.
Mr Andrew Jackson Greater Manchester and Cheshire Cardiac network
Dr Jith Joseph Central and Eastern Cheshire P.C.T.
Dr Ian Milnes Oldham P.C.T.
Dr Washik Parkar Manchester P.C.T.
Dr Masud Prodhan Trafford P.C.T.
Mrs Andrea Saycell Royal Oldham Hopsital
Dr Kenneth Shearer Manchester P.C.T.
Dr Linda Stalley Salford P.C.T
Dr Mark White Stockport P.C.T.
Dr Adu Yusuf Tameside and Glossop P.C.T.