page175
Patients with mild or moderate stable angina should be
given a beta-blocker (section 2.4).
In those with left-
ventricular dysfunction,
beta-blocker treatment should
be started at a very low dose and titrated very slowly
over a period of weeks or months (section 2.5.5).
For those patients in whom beta-blockers are not toler-
ated or are contra-indicated, a long-acting nitrate (sec-
tion 2.6.1) or a rate-limiting calcium-channel
blocker
(diltiazem or verapamil,
section 2.6.2)
can be used;
in
patients with left-ventricular dysfunction,
diltiazem and
verapamil
are contra-indicated because heart
failure
may be precipitated (important:
see p.
128);
however,
a long-acting dihydropyridine calcium-channel
blocker,
such as amlodipine or felodipine, is suitable. Nicorandil
or ivabradine (section 2.6.3) are alternatives.
When a single drug fails to control symptoms, combina-
tion treatment can be used.
A calcium-channel blocker
can be added to a beta-blocker,
although combining
verapamil
with a beta-blocker should be avoided (see
p.
133);
combinations including diltiazem and a beta-
blocker
should
be
used
with
caution.
Long-acting
nitrates can also be used with a beta-blocker or a cal-
cium-channel blocker, if appropriate. Combinations that
include nicorandil or ranolazine (section 2.6.3) can also
be considered.
Patients should be referred to a specialist if a combina-
tion of two drugs fails to control symptoms. Revascular-
isation procedures may be appropriate;
see section 2.9
for the use of antiplatelet drugs in patients undergoing
coronary stenting.
For long-term prevention of cardiovascular events,
see
Prevention of cardiovascular events,
p.
156.
Acute coronary syndromes
Acute coronary syndromes encompass a spectrum of
conditions which include unstable angina,
and myo-
cardial infarction with or without ST-segment elevation.
Patients with different acute coronary syndromes may
present
similarly;
definitive diagnosis is made on the
basis of
clinical
presentation,
ECG changes,
and mea-
surement of biochemical cardiac markers.
Unstable angina and non-ST-segment elevation
myocardial
infarction (NSTEMI)
are related acute
coronary syndromes that fall between the classifications
of
stable angina and ST-segment elevation myocardial
infarction (STEMI).
They usually occur as a result
of
atheromatous plaque rupture,
and are often charac-
terised by stable angina that suddenly worsens,
recur-
ring or prolonged angina at rest, or new onset of severe
angina. Patients with unstable angina have no evidence
of myocardial necrosis, whereas in NSTEMI, myocardial
necrosis
(less
significant
than with STEMI)
will
be
evident.
There is a risk of
progression to STEMI
or
sudden death,
particularly in patients who experience
pain at rest.
ST-segment
elevation
myocardial
infarction
(STEMI)
is an acute coronary syndrome where ather-
omatous plaque rupture leads to thrombosis and myo-
cardial ischaemia, with irreversible necrosis of the heart
muscle,
often
leading
to
long-term complications.
STEMI can also occasionally occur as a result of
cor-
onary
spasm or
embolism,
arteritis,
spontaneous
thrombosis,
or sudden severe elevation in blood pres-
sure.
Management of unstable angina and
non-ST-segment elevation myocardial
infarction
These conditions are managed similarly;
the aims of
management
are to provide supportive care and pain
relief
during the acute attack and to prevent
further
cardiac events and death.
For advice on the manage-
ment of patients with acute ST-segment elevation myo-
cardial infarction (STEMI),
see below.
Initial management
Oxygen (section 3.6) should be
administered if there is evidence of hypoxia, pulmonary
oedema, or continuing myocardial ischaemia; hyperoxia
should be avoided and particular
care is required in
patients with chronic obstructive airways disease.
Nitrates (section 2.6.1)
are used to relieve ischaemic
pain.
If
sublingual
glyceryl
trinitrate is not
effective,
intravenous or buccal
glyceryl
trinitrate or intravenous
isosorbide dinitrate is given. If pain continues, diamor-
phine or morphine (section 4.7.2) can be given by slow
intravenous injection;
an antiemetic such as metoclo-
pramide should also be given (section 4.6).
Aspirin (chewed or dispersed in water) is given for its
antiplatelet effect in a dose of
300 mg (section 2.9).
If
aspirin is given before arrival at hospital,
a note saying
that it has been given should be sent with the patient.
Clopidogrel in a dose of 300 mg (or 600 mg [unlicensed]
if
used prior
to percutaneous coronary intervention)
should also be given (see section 2.9).
Prasugrel,
in a
dose of 60 mg, is an alternative to clopidogrel in certain
patients undergoing percutaneous coronary interven-
tion (see NICE guidance,
p.
150).
Patients should also
receive either unfractionated heparin, a low molecular
weight heparin,
or fondaparinux (section 2.8.1).
Patients without contra-indications should receive beta-
blockers (section 2.4) which should be continued inde-
finitely.
In patients without left ventricular dysfunction
and in whom beta-blockers are inappropriate, diltiazem
or verapamil can be given (section 2.6.2).
The glycoprotein IIb/IIIa inhibitors
eptifibatide and
tirofiban (section 2.9)
can be used (with aspirin and
unfractionated heparin) for unstable angina or for non-
ST-segment elevation myocardial
infarction in patients
at a high risk of either myocardial infarction or death.
In intermediate- and high-risk patients, abciximab, epti-
fibatide,
or tirofiban can also be used with aspirin and
unfractionated heparin in patients undergoing percuta-
neous coronary intervention,
to reduce the immediate
risk of vascular occlusion. In intermediate- and high-risk
patients in whom early intervention is planned,
bivalir-
udin (section 2.8.1) can be considered as an alternative
to the combination of
a glyocprotein IIb/IIIa inhibitor
plus a heparin.
Revascularisation procedures are often appropriate for
patients with unstable angina or non-ST-segment eleva-
tion myocardial infarction (NSTEMI); see section 2.9 for
the use of
antiplatelet
drugs
in patients
undergoing
coronary stenting.
Long-term management
The need for
long-term
angina treatment
or for coronary angiography should
be assessed. Most patients will require standard angina
treatment (see management of stable angina, above) to
prevent recurrence of symptoms.
BNF 61
2.10.1 Management of stable angina and acute coronary syndromes
155
2
Cardiovascular system