6th March 2024

Management

Monotherapy with a beta blocker or rate limiting calcium/non dihydropyridine channel blocker (verapamil, diltiazem) should be initiated and titrated to the maximum tolerated dose. If a beta blocker cannot be tolerated, consider switching to a calcium channel blocker and vice versa. If symptoms persist despite maximum monotherapy dose, a combination of beta blocker and a long acting dihydropyridine calcium channel blocker may be used.

Where a beta blocker or calcium channel blocker cannot be added and symptoms are not controlled on monotherapy, the following may be considered: 

• A long-acting nitrate – Isosorbide mononitrate
• Ivabradine 
• Nicorandil 
• Ranolazine 

If symptoms are not controlled on dual beta-blocker and calcium channel blocker therapy, then consider adding only one of the above-mentioned drugs while the patient awaits revascularisation (PCI or CABG). A GTN spray should be offered to everyone in order to abort anginal attacks. 

For secondary prevention of coronary vascular disease patients should receive aspirin 75mg daily; a statin and have blood pressure and diabetes optimised. In patients with angina and diabetes consider offering an ACE-inhibitor.