• Review the person every 6 months to 1 year depending on the stability of their angina and their comorbidities.
• Check for ongoing symptoms of angina (at rest or with exercise).
• If the person is taking anti-anginal treatment but has persistent symptoms, see Poor control on treatment for advice on further treatment and referral.
• Assess cardiovascular disease risk and identify any modifiable cardiovascular risk factors:
• For information on cardiovascular risk factors, see Managing cardiovascular risk.
• Check for any complications of angina or treatment.
• Check the person's heart rate and blood pressure.
• Check for signs and symptoms of heart failure (for example breathlessness, fatigue, or ankle swelling).
• Screen for low mood or depression using the two questions:
• During the past month, have you often been bothered by feeling down, depressed, or hopeless?
• During the past month, have you often been bothered by having little interest or pleasure in doing things?
• Check compliance, and identify and manage drug interactions and complications of treatment (see Prescribing information).
• Review the person's medication.
• If the person is taking treatment for symptom control, ensure that they are taking a beta-blocker (unless this is contraindicated or not tolerated).
• Ensure that the person is taking aspirin and a statin (unless these are contraindicated or not tolerated).
• Consider whether an angiotensin-converting enzyme inhibitor is indicated.
• See Drug treatment for further information.
• Provide information on angina.
• Provide written information (if this has not already been given).
• Explain when to seek further medical advice (such as worsening symptoms).
• For more information on patient education, see www.bhf.org.uk.

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 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

• 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

• If the person has poorly controlled angina symptoms, see Referral.
• If the person is stable on treatment, referral to a cardiologist is not usually required. However, refer promptly if:
• Stress testing (for example exercise tolerance testing) has not been done as part of the diagnostic process.
• The result of stress testing was highly abnormal, but the person has not been reviewed by a specialist.
• A murmur is detected that has not been assessed by a specialist.
• Also consider referral if:
• There are several risk factors or a strong family history.
• The person requests it.
• There are problems with employment or life insurance.
• A significant comorbidity (such as diabetes) is present.

In depth