NICE guidelines - Treatment of stable angina

This new guideline outlines the best treatment strategies. By Dr Leonard Jacob and Dr Jonathan Shribman

Angiogram showing coronary stenosis - a cause of angina (Photograph: SPL)
Angiogram showing coronary stenosis - a cause of angina (Photograph: SPL)

Prompt treatment of stable angina with optimal medical treatment first and then cardiac intervention when necessary, is a primary aim of evidence-based management of patients with this common condition.

This management strategy aims to relieve the symptoms, improve quality of life and long-term morbidity and mortality. 

The new NICE guideline is based on systematic reviews of the best available evidence for the treatment of stable angina. In addition the guideline development group (GDG) took into consideration the need for informing and engaging patients and their families and/or carers about the nature of the various modalities of treatment.

The management measures described in this guideline apply to all patients irrespective of age, gender or ethnicity.

Key points
  • Lifestyle changes  are vital in the management of stable angina, including  smoking cessation, healthy diet, weight loss and control of lipid levels
  • Associated conditions, such as hypertension and diabetes, should be treated according to relevant guidance
  • Anti-anginal drugs should be titrated to the optimal licensed dose to control symptoms
  • Revascularisation should be considered in patients with left main stem disease or three vessel disease

General measures
After confirming a diagnosis of stable angina using the NICE guideline Chest pain of recent onset, the new guideline emphasises the importance of lifestyle changes in the management of stable angina, including  smoking cessation, healthy diet with adequate intake of fish, fruit and vegetables, exercise as tolerated, weight loss and control of lipid levels. The GDG found no evidence for any benefit in prescribing fish oil or multivitamins in the treatment of stable angina.

Associated conditions, for example hypertension, diabetes, anaemia and valvular disease, should all be treated according to relevant NICE guidance. Aspirin should be considered for secondary prevention of cardiovascular events such as MI and stroke, and statins should be given according to relevant guidance.  

ACE-inhibitor drugs should be offered if the patient has diabetes and they should be continued if already taken for other comorbidities.

Anti-anginal drugs
The new NICE guideline, in line with others, states that short-acting nitrates should be prescribed for all patients with stable angina, with a full explanation of their effects and side effects given to patients and their carers. They should be used for immediate relief of acute symptoms and also in anticipation of an angina episode where possible.

The new guideline is based on an evaluation of the available evidence on all licensed anti-anginal drugs. As described in the guideline, the doses of these drugs should be titrated to the optimal licensed dose to control symptoms. 

The effectiveness of first-line drug therapy - for example, beta blockers (BB) or calcium channel blockers (CCB) - as a single or as an added agent has been clarified in the guideline, as has the need for these to be monitored and reviewed regularly.

In addition, the guideline clarifies the use of the newer anti-anginal medications ivabradine and ranolazine as monotherapy when the first-line drugs are either contraindicated or not tolerated, and as an add-on therapy to one of the first-line drugs if the symptoms are not controlled with a BB and/or CCB and the patient is awaiting revascularisation.

Patients whose symptoms are well controlled on optimal drug treatment (one or two anti-anginal drugs), should not be offered a third anti-anginal drug. They should have the opportunity to discuss their prognosis and the benefits of further investigations and possible revascularisation in the event that they have left main stem disease or three vessel disease.

In the latter two cases, CABG should be considered. There is no RCT evidence  in the modern statin /aspirin era showing that revascularisation is better than optimal medical therapy but cohort non-RCT trials suggest benefit for revascularisation in the above two groups.

Revascularisation
The guidance highlights the importance of optimising medical therapy before considering revascularisation. For those patients who remain symptomatic after optimal medical therapy, a review of the diagnosis together with a review of anatomical and/or functional tests is needed before offering revascularisation with CABG or percutaneous coronary intervention (PCI).

This is best decided by a multi-disciplinary team which should include a cardiologist and a cardiac surgeon. The patients or their carers should discuss the decision, including the possibility that a repeat revascularisation may be needed after either procedure, albeit slightly more frequently after PCI, in addition to the potential survival advantage with CABG in certain cases.

There is also a clear recommendation about the preference of CABG to PCI and vice versa. Those patients who have multi-vessel disease and are aged 65 years and older and/or who have diabetes and also those with lesions not suitable for PCI, should be considered for CABG.

However, when either procedure would be appropriate, the risks and benefits of PCI and CABG for those with anatomically less complex disease should be explained. If the person does not express a preference, offer PCI in preference to CABG based on the evidence that suggests that PCI may be a more cost-effective solution.

The evidence showed stroke to be uncommon after either CABG or PCI, with the incidence being similar after both procedures.

Conclusion
The GDG recognised that the guideline’s evidence-based 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, will surprise many.

They also recognised the limitations in the evidence base and this is demonstrated in a number of clear research recommendations that have been made in order to inform future updates of the guideline.

In addition, a number of implementation tools have been developed to help with the treatment and care of stable angina. This includes a costing statement and a slide set.

A fact sheet has also been produced that helps explain the recommendations on revascularisation in the guideline. It summarises the evidence behind the recommendations and presents a detailed literature review.

  • The NICE guideline, Treatment of stable angina, was published on 27 July 2011 and is available on the NICE website at: www.nice.org.uk/CG126
  • Dr Jacob is a GPSI in cardiology and cardiovascular disease lead, NHS Rotherham and Dr Shribman is a GPSI in cardiology in Stonegables, Northants. Both authors are members of the guideline development group.

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