• For symptom relief:
• Sublingual glyceryl trinitrate should be used for the rapid relief of the symptoms of angina and before performing activities known to cause symptoms of angina.
• Prescribe a beta-blocker as first-line regular treatment to reduce the symptoms of stable angina.
• If a beta-blocker is contraindicated or not tolerated, prescribe a calcium-channel blocker (CCB), a nitrate (such as isosorbide mononitrate), or nicorandil.
• Ivabradine is an alternative to a CCB, a nitrate, or nicorandil if a beta-blocker is contraindicated or not tolerated. However, there is less experience with its use in primary care, and it is significantly more expensive than alternative anti-anginal drugs. Primary care prescribers may wish to consider seeking advice from a specialist before initiating ivabradine in primary care, particularly if they are not familiar with its use.
• To improve prognosis:
• All people with stable angina should be taking low-dose aspirin and a statin unless these are contraindicated or not tolerated.
• All people with stable angina should be considered for treatment with an angiotensin-converting enzyme (ACE) inhibitor.
• For people with stable angina and coexisting hypertension, diabetes, heart failure, asymptomatic left ventricular dysfunction, or previous myocardial infarction, an ACE inhibitor should be prescribed unless this is contraindicated or not tolerated.
• For people with stable angina and no coexisting indications for treatment with an ACE inhibitor, any anticipated benefit of treatment should be considered, alongside the costs and potential risks, on an individual basis.

In depth

• Consider hospital admission for people with the following symptoms, as they may have unstable angina:
• Pain at rest (which may occur at night).
• Pain on minimal exertion.
• Angina that seems to be progressing rapidly despite increasing medical treatment.
• Indications for early referral to a cardiologist include:
• Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty and development of angina.
• Electrocardiographic evidence of previous myocardial infarction or other significant abnormality.
• Newly diagnosed atrial fibrillation.
• Heart failure and angina.
• An ejection systolic murmur suggesting aortic stenosis.
• Any suggestion of hypertrophic cardiomyopathy (for example by family history, physical examination, or electrocardiographic abnormality).
• Refer for prognostic exercise testing if this has not been done as part of the diagnostic process.
• Further reasons to refer people to a cardiologist include:
• Doubt about the diagnosis.
• The presence of several risk factors or a strong family history.
• The person's preference for referral.
• Problems with employment, life insurance, or unacceptable interference with lifestyle.
• Significant comorbidity (such as diabetes).

In depth

All people with angina are assumed to be at high risk for cardiovascular events, and their cardiovascular risk factors should be managed accordingly.

• Optimize the management of comorbid conditions that give an increased risk of cardiovascular events (such as hypertension, diabetes mellitus, and hyperlipidaemia).
• Advise and assist all people who smoke to stop (see the CKS topic on Smoking cessation).
• Encourage people to eat a cardioprotective diet (see the section on Cardioprotective diet in the CKS topic on CVD risk assessment and management).
• Offer advice and support, to achieve and maintain a healthy weight, to people who are overweight or obese (see the CKS topic on Obesity).
• Encourage people to increase their physical activity levels within the limits set by their symptoms. For a detailed discussion on recommended levels of physical activity for cardiovascular protection, see the section on Physical activity in the CKS topic on CVD risk assessment and management.
• Encourage people to limit their alcohol consumption.
• Advise men to limit their alcohol intake to 3–4 units a day, with at most 21 units a week.
• Advise women to limit their alcohol intake to 2–3 units a day, with at most 14 units a week.
• For more information, see the CKS topic on Alcohol - problem drinking.

In depth

• Advise the person that it is their responsibility to inform the Driver and Vehicle Licensing Agency (DVLA) of any condition that may affect their ability to drive.
• The DVLA's medical rules regarding angina are:
• For group 1 entitlement (cars, motorcycles):
• Driving must cease when symptoms occur at rest, with emotion, or at the wheel.
• Driving may recommence when satisfactory symptom control is achieved.
• The DVLA need not be notified.
• For group 2 entitlement (lorries, buses):
• Refusal or revocation of a driver's license may occur if symptoms (treated or untreated) continue.
• Re-licensing may be permitted thereafter provided that the person has been free from angina for at least 6 weeks, exercise or other functional test requirements can be met, and there is no other disqualifying condition.
• The person should check with their insurer that they are still covered for driving.
• The latest information from the DVLA regarding medical fitness to drive can be obtained at www.dvla.gov.uk/medical/ataglance.

In depth

• Advise the person that, if they can briskly climb up and down two flights of stairs without any symptoms of angina, sexual activity is unlikely to precipitate an episode of angina.
• If sexual activity does precipitate an episode of angina, sublingual glyceryl trinitrate taken immediately before intercourse may help prevent subsequent attacks.
• The concomitant use of nitrates or nicorandil with phosphodiesterase inhibitors (sildenafil, tadalafil, and vardenafil), often used in the treatment of erectile dysfunction, is contraindicated.
• Advise people with angina who take a phosphodiesterase inhibitor that:
• They should not use glyceryl trinitrate (GTN) for at least 24 hours before taking sildenafil or vardenafil and for at least 48 hours before taking tadalafil.
• They should not use GTN for at least 24 hours after taking sildenafil or vardenafil and for at least 48 hours after taking tadalafil.
• If they have an episode of angina during sexual intercourse, they must not use GTN. They should stop sexual activity and, if their pain does not resolve, they should call for an ambulance.

In depth

• Advise people with angina that:
• Many people with angina can continue to work as before.
• If their job involves heavy manual work, they may need to alter their work practices.
• If their job involves driving, they should consult the Driver and Vehicle Licensing Agency.
• If the person's employer has an occupational health department, they should be encouraged to discuss the options.

In depth