Stable angina: management

Introduction

Angina is pain or constricting discomfort that typically occurs in the front of the chest (but may radiate to the neck, shoulders, jaw or arms) and is brought on by physical exertion or emotional stress. Some people can have atypical symptoms, such as gastrointestinal discomfort, breathlessness or nausea. Angina is the main symptom of myocardial ischaemia and is usually caused by atherosclerotic obstructive coronary artery disease restricting blood flow and therefore oxygen delivery to the heart muscle. The Health Survey for England (2006) reported that around 8% of men and 3% of women aged between 55 and 64 years currently have or have had angina. The figures for men and women aged between 65 and 74 years are around 14% and 8% respectively. It is estimated that almost 2 million people in England currently have or have had angina. Being diagnosed with angina can have a significant impact on a person's quality of life, restricting daily work and leisure activities.

Stable angina is a chronic medical condition with a low but appreciable incidence of acute coronary events and increased mortality. The aim of management is to stop or minimise symptoms, and to improve quality of life and long-term morbidity and mortality. Management options include lifestyle advice, drug treatment and revascularisation using percutaneous or surgical techniques.

Analysis of the comparative efficacy of different treatments for people with stable angina is difficult because of the advances in drug treatment and revascularisation strategies over several decades. Trials of drug treatment versus coronary artery bypass surgery were carried out more than 25 years ago and showed a survival advantage with surgery in patients with severe coronary artery disease. Statins and other secondary prevention treatments were not used when the trials were carried out and these treatments have a significant effect on morbidity and mortality. Percutaneous revascularisation techniques have developed, from balloon angioplasty to bare metal stents and drug eluting stents and each is associated with reduced rates of repeat revascularisation compared with the previous technique. All trials, including trials of revascularisation strategies, have been limited to people considered suitable for the intervention rather than being representative of the whole population with angina.

The recommendations in this guideline relate only to people with a diagnosis of stable angina. Coronary artery disease can also present as acute coronary syndromes, such as unstable angina or myocardial infarction. The NICE guideline on recent-onset chest pain of suspected cardiac arrest origin, covers the diagnosis of stable angina and should be read in conjunction with this guideline.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.