Quality standard

Quality statement 3: Medical treatment before revascularisation

Quality statement 3: Medical treatment before revascularisation

Quality statement

People with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary, before revascularisation is considered.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of local arrangements to ensure that people with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.

Data source: Local data collection.

Process

Proportion of people with stable angina who are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.

Numerator – the number of people in the denominator prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.

Denominator – the number of people with stable angina considered for revascularisation.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure systems are in place to prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary for people with stable angina before revascularisation is considered.

Healthcare professionals prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered in people with stable angina.

Commissioners ensure they commission services that prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary for people with stable angina before considering revascularisation.

People with stable angina are prescribed a short-acting nitrate and 1 or 2 drugs as necessary to prevent angina before revascularisation (an operation to improve blood flow) is considered.

Source guidance

Stable angina: management. NICE guideline CG126 (2010, updated 2016), recommendations 1.3.3, 1.4.8, 1.4.9, 1.4.11, 1.4.12 and 1.5.1.

Definitions of terms used in this quality statement

Prescribing 1 or 2 anti-anginal drugs as necessary

When anti-anginal drugs are contraindicated, not tolerated or when symptoms are not satisfactorily controlled:

  • if the person cannot tolerate a beta-blocker or calcium-channel blocker, consider switching to the other option (calcium-channel blocker or beta-blocker)

  • if the person's symptoms are not satisfactorily controlled on a beta-blocker or a calcium-channel blocker, consider either switching to the other option or using a combination of the 2

  • if the person cannot tolerate beta-blockers and calcium-channel blockers or both are contraindicated, consider monotherapy with 1 of the following drugs:

    • a long-acting nitrate or

    • ivabradine or

    • nicorandil or

    • ranolazine.

  • for people on beta-blocker or calcium-channel blocker monotherapy whose symptoms are not controlled and the other option (calcium-channel blocker or beta-blocker) is contraindicated or not tolerated, consider 1 of the following as an additional drug:

    • a long-acting nitrate or

    • ivabradine or

    • nicorandil or

    • ranolazine.

Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs.

Since the NICE guideline was produced, the Medicines and Healthcare products Regulatory Agency (MHRA) have published advice about safety concerns related to ivabradine (see the ivabradine June 2014 drug safety update and the December 2014 drug safety update) and nicorandil (see the nicorandil January 2016 drug safety update).

When combining ivabradine with a calcium-channel blocker, use a dihydropyridine calcium-channel blocker, for example, slow release nifedipine, amlodipine, or felodipine. [Adapted from the NICE guideline on stable angina, recommendations 1.4.8, 1.4.9, 1.4.11 and 1.4.12]