Prevention of episodes of angina
NICE advises that first line anti-anginal drugs would be either a beta blocker or calcium channel blocker.2 Prescribers will determine which class of drugs to use on an individual patient basis based on co-morbidities, contra-indications and patient preference.
Doses of individual drugs should be titrated to the maximally licensed or tolerated dose to control symptoms. Patient response to treatment should be monitored every 2-4 weeks after starting or changing treatment.
Where first line treatment does not adequately control symptoms a beta blocker and dihydropyridine calcium channel blocker, such as amlodipine, modified release nifedipine or felodipine, should be used in combination. Both drugs should be titrated to the maximally licensed or tolerated dose.
The rate limiting calcium channel blocker verapamil should not be used in combination with beta blockers because of the risk of severe bradycardia, asystole or hypotension. The combination of diltiazem and beta blocker should only be prescribed on specialist advice.
Where either calcium channel blockers or beta blockers are contra-indicated or not tolerated combination therapy with a long acting nitrate, ivabradine, ranolazine or nicorandil could be considered.2
Where both beta blockers and calcium channel blockers are contra-indicated or not tolerated monotherapy with one of the second line agents would be considered.
Patients whose symptoms are not controlled by a combination of two drugs should be referred to a specialist to determine whether revascularisation is appropriate. Where the patient is either awaiting revascularisation or the procedure is considered inappropriate a third antianginal drug should be considered.