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National Clinical Guidelines Centre (UK). Stable Angina: Methods, Evidence & Guidance [Internet]. London: Royal College of Physicians (UK); 2011 Jul. (NICE Clinical Guidelines, No. 126.)

4Guideline summary

4.1. Algorithms

The care pathway is summarised in the following pages. For a more detailed version, please refer to the quick reference guide for stable angina, which is available from www.nice.org.uk/guidance/CG126/QuickRefGuide

Flowchart Icon

Flowchart (PDF, 95K)

4.2. Key priorities for implementation

From the full set of recommendations, the GDG selected key priorities for implementation. The criteria used for selecting these recommendations are listed in detail in The Guidelines Manual7. The reasons that each of these recommendations were chosen are shown in the table in Appendix I.

The following recommendations have been identified as priorities for implementation.

  • Explore and address issues according to the person’s needs, which may include:
    • self-management skills such as pacing their activities and goal setting
    • concerns about the impact of stress, anxiety or depression on angina
    • advice about physical exertion including sexual activity.
  • Offer people optimal drug treatment for the initial management of stable angina. Optimal drug treatment consists of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease.
  • Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment.
  • When either procedure would be appropriate, explain to the person the risks and benefits of PCI and CABG for people with anatomically less complex disease whose symptoms are not satisfactorily controlled with optimal medical treatment. If the person does not express a preference, take account of the evidence that suggests that PCI may be the more cost-effective procedure in selecting the course of treatment.
  • When either procedure would be appropriate, take into account the potential survival advantage of CABG over PCI for people with multivessel disease whose symptoms are not satisfactorily controlled with optimal medical treatment and who:
    • have diabetes or
    • are over 65 years or
    • have anatomically complex three-vessel disease, with or without involvement of the left main stem.
  • Consider the relative risks and benefits of CABG and PCI for people with stable angina using a systematic approach to assess the severity and complexity of the person’s coronary disease, in addition to other relevant clinical factors and comorbidities.
  • Ensure that there is a regular multidisciplinary team meeting to discuss the risks and benefits of continuing drug treatment or the revascularisation strategy (CABG or PCI) for people with stable angina. The team should include cardiac surgeons and interventional cardiologists. Treatment strategy should be discussed for the following people, including but not limited to:
    • people with left main stem or anatomically complex three-vessel disease
    • people in whom there is doubt about the best method of revascularisation because of the complexity of coronary anatomy, the extent of stenting required or other relevant clinical factors and comorbidities.
  • Ensure people with stable angina receive balanced information and have the opportunity to discuss the benefits, limitations and risks of continuing drug treatment, CABG and PCI to help them make an informed decision about their treatment. When either revascularisation procedure is appropriate, explain to the person:
    • The main purpose of revascularisation is to improve the symptoms of stable angina.
    • CABG and PCI are effective in relieving symptoms.
    • Repeat revascularisation may be necessary after either CABG or PCI and the rate is lower after CABG.
    • Stroke is uncommon after either CABG or PCI, and the incidence is similar between the two procedures.
    • There is a potential survival advantage with CABG for some people with multivessel disease.
  • Discuss the following with people whose symptoms are satisfactorily controlled with optimal medical treatment:
    • their prognosis without further investigation
    • the likelihood of having left main stem disease or proximal three-vessel disease
    • the availability of CABG to improve the prognosis in a subgroup of people with left main stem or proximal three-vessel disease
    • the process and risks of investigation
    • the benefits and risks of CABG, including the potential survival gain.

4.3. Full list of recommendations

1.1. Diagnosis

1.1.1.

Diagnose stable angina according to ‘Chest pain of recent onset’ (NICE clinical guideline 95). Diagnose and manage unstable angina and NSTEMI according to ‘Chest pain of recent onset’ (NICE clinical guideline 95), ‘Unstable angina and NSTEMI’ (NICE clinical guideline 94) and ‘MI: secondary prevention’ (NICE clinical guideline 48).

1.2. Information and support for people with stable angina

1.2.1.

Clearly explain stable angina to the person, including factors that can provoke angina (for example, exertion, emotional stress, exposure to cold, eating a heavy meal) and its long-term course and management. When relevant, involve the person’s family or carers in the discussion.

1.2.2.

Encourage the person with stable angina to ask questions about their angina and its treatment. Provide opportunities for them to voice their concerns and fears.

1.2.3.

Discuss the person’s, and if appropriate, their family or carer’s ideas, concerns and expectations about their condition, prognosis and treatment. Explore and address any misconceptions about stable angina and its implications for daily activities, heart attack risk and life expectancy.

1.2.4.

Advise the person with stable angina to seek professional help if there is a sudden worsening in the frequency or severity of their angina.

1.2.5.

Discuss with the person the purpose and any risks and benefits of their treatment.

1.2.6.

Assess the person’s need for lifestyle advice (for example about exercise, stopping smoking, diet and weight control) and psychological support, and offer interventions as necessary.

1.2.7.

Explore and address issues according to the person’s needs, which may include:

  • self-management skills such as pacing their activities and goal setting
  • concerns about the impact of stress, anxiety or depression on angina
  • advice about physical exertion including sexual activity.

1.3. General principles for treating people with stable angina

1.3.1.

Do not exclude people with stable angina from treatment based on their age alone.

1.3.2.

Do not investigate or treat symptoms of stable angina differently in men and women or in different ethnic groups.

Preventing and treating episodes of angina

1.3.3.

Offer a short-acting nitrate for preventing and treating episodes of angina. Advise people with stable angina:

  • how to administer the short-acting nitrate
  • to use it immediately before any planned exercise or exertion
  • that side effects such as flushing, headache and light-headedness may occur
  • to sit down or find something to hold on to if feeling light-headed.
1.3.4.

When a short-acting nitrate is being used to treat episodes of angina, advise people:

  • to repeat the dose after 5 minutes if the pain has not gone
  • to call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose.

Drugs for secondary prevention of cardiovascular disease

1.3.5.

Consider aspirin 75 mg daily for people with stable angina, taking into account the risk of bleeding and comorbidities.

1.3.6.

Consider angiotensin-converting enzyme (ACE) inhibitors for people with stable angina and diabetes. Offer or continue ACE inhibitors for other conditions, in line with relevant NICE guidance.

1.3.7.

Offer statin treatment in line with ‘Lipid modification’ (NICE clinical guideline 67).

1.3.8.

Offer treatment for high blood pressure in line with ‘Hypertension’ (NICE clinical guideline 34)1.

Dietary supplements

1.3.9.

Do not offer vitamin or fish oil supplements to treat stable angina. Inform people that there is no evidence that they help stable angina.

1.4. Anti-anginal drug treatment

General recommendations

1.4.1.

Offer people optimal drug treatment for the initial management of stable angina. Optimal drug treatment consists of one or two anti-anginal drugs as necessary plus drugs for secondary prevention of cardiovascular disease.

1.4.2.

Advise people that the aim of anti-anginal drug treatment is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke.

1.4.3.

Discuss how side effects of drug treatment might affect the person’s daily activities and explain why it is important to take drug treatment regularly.

1.4.4.

Patients differ in the type and amount of information they need and want. Therefore the provision of information should be individualised and is likely to include, but not be limited to:

  • what the medicine is
  • how the medicine is likely to affect their condition (that is, its benefits)
  • likely or significant adverse effects and what to do if they think they are experiencing them
  • how to use the medicine
  • what to do if they miss a dose
  • whether further courses of the medicine will be needed after the first prescription
  • how to get further supplies of medicines. [This recommendation is from ‘Medicines adherence’ (NICE clinical guideline 76).]
1.4.5.

Review the person’s response to treatment, including any side effects, 2–4 weeks after starting or changing drug treatment.

1.4.6.

Titrate the drug dosage against the person’s symptoms up to the maximum tolerable dosage.

Drugs for treating stable angina

1.4.7.

Offer either a beta blocker or a calcium channel blocker as first-line treatment for stable angina. Decide which drug to use based on comorbidities, contraindications and the person’s preference.

1.4.8.

If the person cannot tolerate the beta blocker or calcium channel blocker, consider switching to the other option (calcium channel blocker or beta blocker).

1.4.9.

If the person’s symptoms are not satisfactorily controlled on a beta blocker or a calcium channel blocker, consider either switching to the other option or using a combination of the two2.

1.4.10.

Do not routinely offer anti-anginal drugs other than beta blockers or calcium channel blockers as first-line treatment for stable angina.

1.4.11.

If the person cannot tolerate beta blockers and calcium channel blockers or both are contraindicated, consider monotherapy with one of the following drugs:

Decide which drug to use based on comorbidities, contraindications, the person’s preference and drug costs.

1.4.12.

For people on beta blocker or calcium channel blocker monotherapy whose symptoms are not controlled and the other option (calcium channel blocker or beta blocker) is contraindicated or not tolerated, consider one of the following as an additional drug:

Decide which drug to use based on comorbidities, contraindications, the person’s preference and drug costs.

1.4.13.

Do not offer a third anti-anginal drug to people whose stable angina is controlled with two anti-anginal drugs.

1.4.14.

Consider adding a third anti-anginal drug only when:

  • the person’s symptoms are not satisfactorily controlled with two anti-anginal drugs and
  • the person is waiting for revascularisation or revascularisation is not considered appropriate or acceptable.

Decide which drug to use based on comorbidities, contraindications, the person’s preference and drug costs.

1.5. Investigation and revascularisation

People with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment

1.5.1.

Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous coronary intervention [PCI]) for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment.

1.5.2.

Offer coronary angiography to guide treatment strategy for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment. Additional non-invasive or invasive functional testing may be required to evaluate angiographic findings and guide treatment decisions. [This recommendation partially updates recommendation 1.2 of ‘Myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction’ (NICE technology appraisal guidance 73).]

1.5.3.

Offer CABG to people with stable angina and suitable coronary anatomy when:

  • their symptoms are not satisfactorily controlled with optimal medical treatment and
  • revascularisation is considered appropriate and
  • PCI is not appropriate.
1.5.4.

Offer PCI to people with stable angina and suitable coronary anatomy when:

  • their symptoms are not satisfactorily controlled with optimal medical treatment and
  • revascularisation is considered appropriate and
  • CABG is not appropriate.
1.5.5.

When either procedure would be appropriate, explain to the person the risks and benefits of PCI and CABG for people with anatomically less complex disease whose symptoms are not satisfactorily controlled with optimal medical treatment. If the person does not express a preference, take account of the evidence that suggests that PCI may be the more cost-effective procedure in selecting the course of treatment.

1.5.6.

When either procedure would be appropriate, take into account the potential survival advantage of CABG over PCI for people with multivessel disease whose symptoms are not satisfactorily controlled with optimal medical treatment and who:

  • have diabetes or
  • are over 65 years or
  • have anatomically complex three-vessel disease, with or without involvement of the left main stem.
1.5.7.

Consider the relative risks and benefits of CABG and PCI for people with stable angina using a systematic approach to assess the severity and complexity of the person’s coronary disease, in addition to other relevant clinical factors and comorbidities.

1.5.8.

Ensure that there is a regular multidisciplinary team meeting to discuss the risks and benefits of continuing drug treatment or revascularisation strategy (CABG or PCI) for people with stable angina. The team should include cardiac surgeons and interventional cardiologists. Treatment strategy should be discussed for the following people, including but not limited to:

  • people with left main stem or anatomically complex three-vessel disease
  • people in whom there is doubt about the best method of revascularisation because of the complexity of the coronary anatomy, the extent of stenting required or other relevant clinical factors and comorbidities.
1.5.9.

Ensure people with stable angina receive balanced information and have the opportunity to discuss the benefits, limitations and risks of continuing drug treatment, CABG and PCI to help them make an informed decision about their treatment. When either revascularisation procedure is appropriate, explain to the person:

  • The main purpose of revascularisation is to improve the symptoms of stable angina.
  • CABG and PCI are effective in relieving symptoms.
  • Repeat revascularisation may be necessary after either CABG or PCI and the rate is lower after CABG.
  • Stroke is uncommon after either CABG or PCI, and the incidence is similar between the two procedures.
  • There is a potential survival advantage with CABG for some people with multivessel disease.
1.5.10.

Inform the person about the practical aspects of CABG and PCI. Include information about:

  • vein and/or artery harvesting
  • likely length of hospital stay
  • recovery time
  • drug treatment after the procedure.

People with stable angina whose symptoms are satisfactorily controlled with optimal medical treatment

1.5.11.

Discuss the following with people whose symptoms are satisfactorily controlled with optimal medical treatment:

  • their prognosis without further investigation
  • the likelihood of having left main stem disease or proximal three-vessel disease
  • the availability of CABG to improve the prognosis in a subgroup of people with left main stem or proximal three-vessel disease
  • the process and risks of investigation
  • the benefits and risks of CABG, including the potential survival gain.
1.5.12.

After discussion (see 1.5.11) with people whose symptoms are satisfactorily controlled with optimal medical treatment, consider a functional or non-invasive anatomical test to identify people who might gain a survival benefit from surgery. Functional or anatomical test results may already be available from diagnostic assessment. [This recommendation partially updates recommendation 1.2 of ‘Myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction’ (NICE technology appraisal guidance 73).]

1.5.13.

After discussion (see 1.5.11) with people whose symptoms are satisfactorily controlled with optimal medical treatment, consider coronary angiography when:

  • functional testing indicates extensive ischaemia or non-invasive anatomical testing indicates the likelihood of left main stem or proximal three-vessel disease and
  • revascularisation is acceptable and appropriate.
1.5.14.

Consider CABG for people with stable angina and suitable coronary anatomy whose symptoms are satisfactorily controlled with optimal medical treatment, but coronary angiography indicates left main stem disease or proximal three-vessel disease.

1.6. Pain interventions

1.6.1.

Do not offer the following interventions to manage stable angina:

  • transcutaneous electrical nerve stimulation (TENS)
  • enhanced external counterpulsation (EECP)
  • acupuncture.

1.7. Stable angina that has not responded to treatment

1.7.1.

Offer people whose stable angina has not responded to drug treatment and/or revascularisation comprehensive re-evaluation and advice, which may include:

  • exploring the person’s understanding of their condition
  • exploring the impact of symptoms on the person’s quality of life
  • reviewing the diagnosis and considering non-ischaemic causes of pain
  • reviewing drug treatment and considering future drug treatment and revascularisation options
  • acknowledging the limitations of future treatment
  • explaining how the person can manage the pain themselves
  • specific attention to the role of psychological factors in pain
  • development of skills to modify cognitions and behaviours associated with pain.

1.8. Cardiac syndrome X

1.8.1.

In people with angiographically normal coronary arteries and continuing anginal symptoms, consider a diagnosis of cardiac syndrome X.

1.8.2.

Continue drug treatment for stable angina only if it improves the symptoms of the person with suspected cardiac syndrome X.

1.8.3.

Do not routinely offer drugs for the secondary prevention of cardiovascular disease to people with suspected cardiac syndrome X.

4.4. Key research recommendations

Adding a newer anti-anginal drus to a calcium channel blocker

What is the clinical and cost effectiveness of adding a newer anti-anginal drug (nicorandil, ivabradine or ranolazine) to a calcium channel blocker for treating stable angina?

Management of stable angina in people with evidence of ischaemia on non-invasive functional testing

Do people with stable angina and evidence of reversible ischaemia on non-invasive functional testing who are on optimal drug treatment benefit from routine coronary angiography with a view to revascularisation?

Early revascularisation strategy for people with angina and multivessel disease

In people with stable angina and multi-vessel disease (including left main stem [LMS] disease) whose symptoms are controlled on optimal drug treatment, would an initial treatment strategy of revascularisation be clinically and cost effective compared with continued drug treatment?

Cardiac rehabilitation

Is an 8-week, comprehensive, multidisciplinary, cardiac rehabilitation service more clinically and cost effective for managing stable angina than current clinical practice?

Patient self-management plans

What is the clinical and cost effectiveness of a self-management plan for people with stable angina?

Footnotes

1

NICE is updating clinical guideline 34 on hypertension (publication expected August 2011).

2

When combining a calcium channel blocker with a beta blocker, use a dihydropyridine calcium channel blocker, for example, slow release nifedipine, amlodipine or felodipine.

Copyright © 2011, National Clinical Guidelines Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of the National Clinical Guidelines Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Cover of Stable Angina
Stable Angina: Methods, Evidence & Guidance [Internet].
NICE Clinical Guidelines, No. 126.
National Clinical Guidelines Centre (UK).

NICE (National Institute for Health and Care Excellence)

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