KISS: Stable Angina

KISS Header

Based on BMJ2016;352;i205, NEJM2016;374;1167, CKS 2015, and NICE CG126

  • Cardiovascular risk reduction
    • Lifestyle change and lifestyle risk factor modification +++
    • Aspirin 75mgs daily is the preferred single antiplatelet; clopidogrel is preferred if co-existent peripheral arterial disease or if aspirin not tolerated. Dual therapy is only recommended in stable angina after PCI for up to one year.
    • Statin, current guidance is for atorvastatin 80mg daily NICE Lipid Guidelines 2014
    • consider ACEi or low-cost ARB if stable angina and diabetes, previous MI, CKD or LV systolic dysfunction as they improve mortality in these groups. Recent research confirms they do not improve outcomes BMJ2017;356;j4. in patients with stable CAD but without heart failure
    • GTN prn
      • Ensure spray is always in date, and carried at all times
      • If develop chest pain, stop activity and take immediately
      • Repeat the dose at 5 minutes, if the pain persists at 5 minutes call 999
    • Symptomatic drug treatment (none of these drugs have been shown to reduce cardiovascular events with the exception of beta-blockers after MI and in heart failure)
      • Offer either a BB or CCB as first-line based on co-morbidities and patient preference
        • If either not tolerated, switch to the other
        • If either ineffective, switch to the other or combine the two
      • If both contraindicated or not tolerated, consider monotherapy with one of
        • Long-acting nitrate, such as isosorbide mononitrate
        • Nicorandil (be aware of risk of skin, mucosal and eye ulceration including gastrointestinal; increased risk with antiplatelets Drug Safety Update 2016)
        • Ivabradine or Ranolazine
          • Ivabradine: The Drug Safety Update in June 2014 has highlighted the need to carefully monitor for bradycardia. Concomitant use with rate limiting CCB such as diltiazem and verapamil should be avoided.
      • Adding second drugs
        • CCB plus BB is preferred combination (see below)
        • If not possible, options are BB or CCB plus one of the second-line drugs above
      • If remain symptomatic on two drugs, refer for consideration of PCI

Prescribing notes

  • Beta Blockers (NB it is no longer essential for patients to be on indefinite BB)
    • Atenolol 100mgs, or metoprolol 50-100mg bd, orbisoprolol 5-20mg
  • CCB
    • Use rate limiting CCB e.g. diltiazem (unless heart failure or heart block, in which case use amlodipine)
  • BB plus CCB
    • BB + amlodipine safe
    • BB + diltiazem has been used successfully in trials
    • BB + verapamil AVOID
Published on 25th January 2017