Angina Pectoris: Drug Management

Key points

• All patients: aspirin + statin (unless contraindicated), plus sublingual GTN to abort attacks.
• First-line anti-anginal: a beta-blocker OR a calcium-channel blocker, chosen by comorbidities, contraindications and preference.
• CCB monotherapy should be rate-limiting (verapamil/diltiazem); when combined with a beta-blocker use a long-acting dihydropyridine (e.g. MR nifedipine, amlodipine). NEVER combine a beta-blocker with verapamil (risk of complete heart block).
• If symptoms persist on one drug, switch to or add the other class. Third-line (only if not controlled on two drugs and awaiting or unsuitable for revascularisation): add a long-acting nitrate, ivabradine, nicorandil or ranolazine. Do NOT add a third anti-anginal if already controlled on two.
• Consider revascularisation (PCI or CABG) if symptoms are not controlled on optimal medical therapy. Aspirin and statin are for prognosis; ACE-inhibitor benefit is modest unless there is diabetes or another indication.

Decision points in this pathway

• First-line agent choice?
• Still symptomatic on monotherapy?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.