People currently on monotherapy:

• Ensure that the person is taking the maximum licensed or highest tolerated dose.
• If the person is taking a beta-blocker:
• Add a long-acting dihydropyridine calcium-channel blocker (CCB), such as amlodipine, modified-release nifedipine, or modified-release felodipine.
• If a dihydropyridine CCB is contraindicated or not tolerated, add a nitrate; nicorandil; or ivabradine (if their heart rate is > 60 bpm).
• If the person is taking an anti-anginal drug other than a beta-blocker, and is not known to be intolerant of a beta-blocker and has no contraindications:
• Consider adding a beta-blocker.
• Do not combine a beta-blocker with a rate-limiting CCB (diltiazem or verapamil).
• If the person is taking an anti-anginal drug other than a beta-blocker, and a beta-blocker is contraindicated or not tolerated:
• If taking a CCB, add a nitrate or nicorandil.
• If taking a nitrate, add a CCB or nicorandil.
• If taking nicorandil, add a CCB or a nitrate.
• If taking ivabradine, add a dihydropyridine CCB, a nitrate, or nicorandil (consider seeking specialist advice).

For people on dual therapy:

• Ensure that the person is taking the maximum licensed or highest tolerated dose of each drug.
• If symptom control is poor on the maximum licensed or tolerated doses of two drugs, refer to a cardiologist (for advice on further drug management and assessment for revascularization).
• Consider starting a third anti-anginal drug while awaiting referral.

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:
• No previous stress test (such as exercise tolerance test).
• Failure to respond to medical treatment (maximum therapeutic doses of two drugs).
• A highly abnormal exercise tolerance test.
• Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty.
• Newly diagnosed or uncontrolled atrial fibrillation.
• Electrocardiographic evidence of a previous myocardial infarction or other significant abnormality.
• Ejection systolic murmur suggesting aortic stenosis.
• Further reasons to refer to a cardiologist include:
• 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