Primary cause: Coronary artery disease (CAD) due to atherosclerosis
Other causes: Aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM), coronary artery spasm

Symptoms

Management

Pharmacological (Stepwise Approach)

Line	Medications & Notes
1st Line	GTN spray 400–800 mcg SL, repeat every 5 min up to 3 doses. Use before exertion
2nd Line	Beta-blockers (e.g., Atenolol 25–100 mg OD, Metoprolol 25–100 mg BID). If LVEF <40%, use carvedilol/bisoprolol. OR Non-DHP CCB (if BB not tolerated)
3rd Line	Add dihydropyridine CCB (e.g., Amlodipine 2.5–10 mg OD) alongside BB
4th Line	Replace CCB if ineffective: Long-acting nitrates (e.g., Isosorbide mononitrate 30–120 mg OD)
Last Line	Nicorandil 5–20 mg BID for refractory cases

Non-Pharmacological

Lifestyle: Smoking cessation, regular exercise (150 min/week), weight management (BMI <25), healthy diet
Avoid: Dihydropyridine + non-DHP CCBs (risk of bradycardia)

Special Considerations

Heart failure: Use carvedilol/bisoprolol if EF <40%. Avoid BB + verapamil/diltiazem
Nitrate tolerance: Limit patch use to 14 hrs/day
Refractory angina: Consider nicorandil or specialist referral

Complications

Angina

Aetiology/Causes:

Primarily caused by coronary artery disease (CAD) due to atherosclerosis, leading to reduced myocardial oxygen supply.
Other conditions include aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM), and coronary artery spasm.

Symptoms:

Retrosternal chest pain radiating to shoulders, neck, jaw, or arms.
Triggered by physical exertion or emotional stress and relieved by rest or nitroglycerin.
Pain typically lasts less than 10 minutes.

Differential Diagnosis:

Investigations:

Test	Purpose
ECG	Identify ischaemia-related changes (e.g., ST depression)
Blood tests (i.e., troponin)	Rule out myocardial infarction
Stress ECG/Echo	For intermediate pre-test probability of ischaemic heart disease (IHD)
Exercise stress test	Assess for exercise-induced ischaemia
Coronary angiography	Determine extent of coronary artery blockage Suitable if persistent symptoms with normal stress test
Catheter coronary angiogram	Indicated in high-risk acute coronary syndrome (ACS)
Myocardial Perfusion Scan	Not for typical angina; consider if stress test results are inconclusive

Management:

Pharmacological Management (Stepwise Approach):

Line of Therapy	Medications and Notes
1st Line	GTN spray 400–800 mcg sublingually, repeat every 5 mins up to 3 doses. Use preventively before exertion. If pain persists >10 mins after 2 sprays, give a 3rd spray and call for help Side effects: headache, flushing, orthostatic hypotension
2nd Line	Add Beta-blockers: Atenolol 25–100 mg daily, Metoprolol tartrate 25–100 mg BID If LVEF <40%, use beta-blockers recommended for heart failure (carvedilol, bisoprolol, nebivolol) OR non-DHP CCB (if BB not tolerated): Diltiazem 180–360 mg daily, or Verapamil 120–480 mg daily (avoid in LVEF <40%)
3rd Line	Add a dihydropyridine CCB (e.g., Amlodipine 2.5–10 mg daily or Nifedipine MR 30–60 mg daily) along with a BB
4th Line	Replace CCB if still no improvement: Long-acting GTN patch 5–15 mg transdermal, max 14 hours/day Isosorbide mononitrate MR 30–120 mg daily (ensure a nitrate-free period)
Last Line	Nicorandil 5–20 mg BID: useful in refractory angina or when combined with other antianginals

Non-Pharmacological Management:

Smoking cessation
Regular aerobic exercise (150 min/week)
Healthy diet with reduced saturated fats
Weight management (target BMI <25)
- Avoid using dihydropyridine CCBs alongside non-DHP CCBs due to the risk of bradycardia.

Special Considerations:

Beta-blockers and Heart Failure: Use heart failure-specific beta-blockers (carvedilol, bisoprolol) if EF <40%. Avoid combining beta-blockers with verapamil/diltiazem due to bradycardia risk.
Nitrate Use: Limit patch to 14 hours/day to prevent tolerance.
Refractory Angina: If two antianginals do not suffice, consider adding nicorandil or specialist referral.

Complications:

Prognosis:

Proper management with lifestyle changes and medication leads to good outcomes. Revascularisation may be needed for high-risk cases.

Notes:

Exercise Considerations: Use GTN before exercise to reduce angina episodes.
Combination Therapy: If dual therapy (i.e., BB + CCB or long-acting nitrate) does not suffice, specialist consultation is advised.
GTN Safety Tips: Instruct patients to sit down before taking GTN spray due to the risk of orthostatic hypotension.
Refractory Angina: Consider perhexiline in patients with refractory symptoms despite optimal therapy or if unsuitable for revascularisation.
Use of Investigations: Stress tests are optimal for patients with intermediate IHD probability. Myocardial perfusion scans are not indicated in patients with typical angina unless further evaluation is needed.
Calcium Scoring: For asymptomatic individuals aged 45–75, calcium scoring may guide management in intermediate risk (10–20%) groups based on the Framingham Risk Equation.
High-Risk Indicators: For high-risk patients (e.g., ACS), immediate angiography is preferred over non-invasive tests.

Preventing Angina

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