This site is intended for UK healthcare professionals
Medscape UK Univadis Logo
Medscape UK Univadis Logo

Welcome to the new home for Guidelines

Summary for secondary care

Secondary Care Management of Stable Angina

This specialist Guidelines summary provides recommendations on the diagnosis and management of stable angina in patients where reduced myocardial perfusion is due to arterial narrowing resulting from underlying atherosclerotic CAD. This guideline does not address the management of chest pain due to other cardiovascular or non-cardiac causes. This summary is intended for use in a secondary care setting by cardiologists.

For managing stable angina in a primary care setting, see our related Guidelines summary here.

For the complete set of recommendations, refer to the full guideline.

Recommendations are marked [R] and good-practice points are marked [✓].

Diagnosis and Assessment

For clinical history, assessment, and non-cardiac chest pain recommendations, please refer to the full guideline.

Algorithm 1: Management Options in Patients with Suspected Angina

photo of

Algorithm 2: Management Options in Patients with a Definite Diagnosis of Stable Angina

photo of

Diagnostic and Prognostic Tools

[R] A resting electrocardiogram (ECG) should be performed in patients with suspected cardiac chest pain.

[R] Computerised tomography–coronary angiography should be considered for the investigation of patients with chest pain in whom the diagnosis of stable angina is suspected but not clear from history alone.

[R] Where appropriate, functional tests, including the exercise tolerance test, should be considered to aid in the risk stratification of patients with known coronary artery disease (CAD). 

[R] In patients with suspected stable angina, the exercise tolerance test should not be used routinely as a first-line diagnostic tool

[✓] Coronary angiography should be considered after non-invasive testing where patients are identified to be at high risk or where a diagnosis remains unclear.

Models of Care

[✓] Following initial assessment in primary care, patients with suspected angina should have the diagnosis confirmed and risk stratification undertaken, when appropriate, in secondary care.

Pharmacological Management

Drug Monotherapy to Alleviate Angina Symptoms

[R] Sublingual glyceryl trinitrate tablets or spray should be used for the immediate relief of angina and before performing activities that are known to bring on angina.

[R] Beta-blockers should be used as first-line therapy for the relief of symptoms of stable angina.

[R] Rate-limiting calcium channel blockers should be considered where beta-blockers

[R] Patients with Prinzmetal (vasospastic) angina should be treated with a dihydropyridine derivative calcium channel blocker, for example (amlodipine, nifedipine).

Combination Therapy to Alleviate Angina Symptoms

[R] When adequate control of anginal symptoms is not achieved with beta blockade, addition of a calcium channel blocker should be considered.

[✓] Rate-limiting calcium channel blockers should be used with caution when combined with beta-blockers.

[✓] Patients whose symptoms are not controlled on maximum therapeutic doses of two drugs should be considered for referral to a cardiologist.

Drug Interventions to Prevent New Vascular Events

[R] All patients with stable angina due to atherosclerotic disease should receive long-term standard aspirin and statin therapy.

[R] All patients with stable angina should be considered for treatment with angiotensin-converting enzyme inhibitors.

Interventional Cardiology and Cardiac Surgery

Percutaneous Coronary Intervention

[R] In patients with stable angina undergoing percutaneous coronary intervention, second- or third-generation drug-eluting stent should be used unless there is a contraindication to prolonged dual antiplatelet therapy.

Coronary Artery Bypass Grafting

[R] Off-pump coronary artery bypass graft can be considered whenever complete revascularisation may be safely achieved, especially in patients with increased risk and comorbidities.

[✓] The decision about whether to use on-pump or off-pump approaches should be based on the familiarity of the surgeon with the technique.

[R] Patients undergoing surgical revascularisation of the left anterior descending coronary artery should receive an internal mammary artery graft.

[R] In patients undergoing multiple coronary artery bypass grafting, use of both internal mammary arteries should be considered.

Choice of Revascularisation Technique

[R] Patients with stable angina who remain symptomatic on optimal medical therapy should be considered for revascularisation by coronary artery bypass grafting or percutaneous coronary intervention.

[R] Patients with left main-stem stenosis and/or multivessel disease should be considered for revascularisation to improve prognosis.

[✓] A tailored approach to revascularisation is required and the approach should be decided following discussion with the patient and the multidisciplinary ‘Heart Team’. Factors influencing the choice of revascularisation should include burden and complexity of CAD, presence of diabetes mellitus, age, and renal dysfunction.

Post Intervention Drug Therapy

[R] Following bare-metal stent implantation, patients with stable angina should receive aspirin and clopidogrel for at least 1 month.

[R] Following drug-eluting stent implantation, patients with stable angina should receive aspirin and clopidogrel for 6 months.

[✓] Following drug-eluting stent implantation, longer courses of dual antiplatelet therapy may be considered for patients at high risk of ischaemic events. Use should be carefully weighted against the increased risk of bleeding.

Managing Restenosis

[R] In patients with stable angina requiring percutaneous coronary intervention for in-stent restenosis a drug-eluting balloon or a second- or third-generation drug-eluting stent should be considered.

Managing Refractory Angina

[R] Transmyocardial laser revascularisation is not recommended for the treatment of stable angina.

Stable Angina and Non-cardiac Surgery

Assessment Prior to Surgery

  • The Revised Cardiac Risk Index is a simple risk-stratification tool that combines patient risk and procedural risk and can aid clinical decision making (Table 1).

Table 1: Revised Cardiac Risk Index

Clinical Factors
  • High-risk surgery
  • History of ischaemic heart disease (IHD)
  • History of congestive heart failure
  • History of cerebrovascular disease
  • Preoperative insulin treatmentPreoperative creatinine >180 micromol/l.
High-risk surgery is defined as intraperitoneal, intrathoracic, or suprainguinal vascular procedures. A history of IHD is defined as any of the following: a history of myocardial infarction, positive exercise tolerance test, current complaint of chest pain of ischaemic origin, use of nitrate therapy or pathological Q waves on ECG. Patients with prior revascularisation are only classified as having IHD if they have one of the above criteria.
[R] As part of the routine assessment of fitness for non-cardiac surgery, a risk-assessment tool should be used to quantify the risk of serious cardiac events in patients with coronary heart disease.

[R] Patients undergoing high-risk surgery who have a history of CAD, stroke, diabetes, heart failure, or renal dysfunction should have further investigation either by exercise tolerance testing or other non-invasive testing or coronary angiography, if appropriate.

[✓] Where high perioperative risk is identified, a strategy for risk reduction should be agreed. This will require teamwork and good communication between surgeon, anaesthetist, perioperative physician, and cardiologist.[R] An objective assessment of the functional capacity should be made as part of the preoperative assessment of all patients with coronary heart disease before major surgery.

Perioperative Revascularisation

[R] Coronary revascularisation is not recommended before major- or intermediate-risk non-cardiac surgery unless cardiac symptoms are unstable and/or coronary artery bypass grafting would be justified on the basis of long-term outcome.

[R] If emergency or urgent non-cardiac surgery is required early after percutaneous coronary intervention (less than 6 weeks following bare-metal stent implantation; less than 3 months following drug-eluting stent implantation), dual antiplatelet therapy should be continued whenever possible. If the bleeding risk is unacceptable and antiplatelet therapy is to be withdrawn prematurely, it should be reintroduced as soon as possible after surgery.

[✓] The indications used for revascularisation prior to non-cardiac surgery should be those used in the non-operative setting.

[✓] Where possible, non-cardiac surgery should be delayed for at least 1 month after coronary artery grafting. When deciding when to operate, the balance of risks and benefits in an individual patient will depend on the severity of the CAD and the nature and urgency of the non-cardiac surgery.

Drug Therapy in Patients Undergoing Non-cardiac Surgery

[R] Routine initiation of perioperative beta-blocker therapy to reduce perioperative myocardial infarction in patients undergoing non-cardiac surgery is not recommended.

[R] Acute withdrawal of beta-blockers in the postoperative period is not recommended.

[✓] If beta-blockers are started perioperatively in patients with myocardial ischaemia, a period of dose titration (weeks to months) is recommended if time permits before undergoing non-cardiac surgery. There is an increased risk of adverse effects in the perioperative period, particularly hypotension and stroke. Measures to address this such as withholding antihypertensive therapy should be considered and blood pressure should be carefully monitored after surgery with appropriate protocols to address hypotension as required.

[R] Alpha-2 adrenergic receptor agonists are not recommended for perioperative risk reduction in patients undergoing non-cardiac surgery.

[R] The routine use of aspirin to reduce perioperative cardiac events in patients undergoing non-cardiac surgery, including those with known stable CAD, is not recommended.

[✓] Perioperative aspirin should be only continued in patients at high thrombotic risk, for example in patients with a recent acute coronary syndrome, coronary artery stents, or an ischaemic stroke.

[✓] Where aspirin is to be discontinued this should be performed at least 3 days prior to non-cardiac surgery.

[R] Patients presenting for non-cardiac surgery who are already on statin therapy should have the statin continued through the perioperative period.

Psychological Health

How Does Angina Affect Quality of Life?

[R] Patients with angina should be assessed by appropriately trained staff for the impact of angina on mood, quality of life, and function, to monitor progress and inform treatment decisions.

[✓] Mood, quality of life, and function in patients with angina can be assessed using validated measures such as:

Improving Symptom Control With Behavioural Interventions

[✓] Any psychoeducational treatments that are shown to reduce distress should be considered alongside conventional surgical and medical therapy.

Provision of Information

Information and Education About Surgery and Other Interventions

[✓] Educational programmes delivered pre- and post-coronary artery bypass grafting should consider the use of strategies based on psychological principles to improve management of risk factors, psychological distress, and physical functioning.

[✓] Patients newly diagnosed with angina and those who are immediately pre- and post-interventions and revascularisation, should be given appropriate information to help them understand their condition and how to manage it, and any procedure being undertaken.

[✓] Health beliefs and misconceptions should be addressed when delivering information.

Cardiac Waiting Times

[R] Early access to angiography and coronary artery bypass surgery may reduce the risk of adverse cardiac events and impaired quality of life.

Follow Up in Patients With Angina

[R] Patients presenting with angina and with a diagnosis of coronary heart disease should receive long-term structured follow up in primary care.

Checklist for Provision of Information

This section gives examples of the information patients/carers may find helpful at the key stages of the patient journey. The checklist was designed by members of the guideline development group based on their experience and their understanding of the evidence base. In developing the checklist, consideration was given to what patients and carers valued. The checklist is neither exhaustive nor exclusive.

This section gives examples of the information patients/carers may find helpful at the key stages of the patient journey.

Box 1: Checklist for Provision of Information
Initial Presentation
  • Offer a reassuring approach to the patients and their families/carers who may be worried or anxious and answer any questions they may have.
  • Explain to the patient it is often difficult to distinguish between indigestion and angina, until all tests are completed a definite diagnosis cannot be made.
  • Listen carefully to the needs and priorities of patients and their families.
  • Explain the need to carry out tests to provide a diagnosis and answer any questions patients and their families have.
Assessment and Investigation
  • Ensure patients are kept informed about which tests will be performed, when they are likely to be carried out and what the results mean.
  • Explain that symptoms of angina are often brought on by physical activity, emotional upset, cold weather, or after a meal.
  • Advise patients of the need to check existing medication and ensure they understand the possible side effects.
  • Provide time to explain the diagnosis. The patient should be reassured and given clear advice on when to seek help in the future.
  • Address any anxieties/worries patients and their families may have and allow time for them to ask questions.
  • Explain to patients how to distinguish between angina and a heart attack and advise them to call 999 if they suspect they are having a heart attack.
  • Give written information to patients and their families, for example British Heart Foundation or Chest, Heart & Stroke Scotland patient information booklets or SIGN patient information.
  • Explain different types of treatment including the risks and benefits of recommended medications and treatment and provide written information as appropriate.
  • Encourage patients and their families to discuss their questions and concerns.
  • Ensure consistent and appropriate information is given to patients and carers.
Follow Up
  • Explain to patients that referral to a cardiac rehabilitation programme will be arranged and what this means.
  • Inform patients of the importance of an annual health check.
  • Offer advice to patients on ways to improve their lifestyle to prevent their angina from getting worse.
  • Ensure patients and their families have all the relevant information about angina.
  • Emphasise the importance of carrying their GTN spray/tablets at all times.
Abbreviation: GTN=glyceryl trinitrate