Mostly from clinical history characterized by chest pain due to myocardial ischaemia usually inducible by exercise, emotion or other stress and reproducible, relieved by rest but may occur spontaneously and stable in nature.

Pharmacological

Pharmacological Treatment

Aspirin soluble 75 – 100mg daily oral. (long-term prophylaxis for arterial thrombosis)

AND

Isosorbide mononitrate 10mg/20mg twice daily oral, or Isosorbide dinitrate 20mg/40mg twice daily oral preferably at 8:00 and 14:00 hours for both medicines to provide a nitrate free period to prevent tolerance. If nitrates cannot be tolerated especially due to nitrate induced severe headache consider stepwise adding other anti-angina medicines below; Add stepwise other anti-angina medicines

Step 1: add ß-blocker if not contraindicated

eg Atenolol12.5/25mg daily oral

OR

Metoprolol 25/50mg daily oral.

If a ß-blocker cannot be tolerated or is contraindicated, consider long acting calcium channel blocker.

Step 2 adds long acting calcium channel blocker.

Verapamil 30mg 2–3 times daily oral

OR

Diltiazem 30mg 2–3 times daily oral, if suspects Prinzmetal Angina.

Key Note:

All patients with stable chronic angina are high-risk for cardiovascular events, should initiate lipid lowering medicines (HMGCoA reductase inhibitors); See Section 20.2 management of dyslipidemias

Therapy requires good initial evaluation, ongoing support for patients and continuous evaluation to ensure compliance. Therapy should be initiated together with appropriate lifestyle modification and adherence monitoring.

Consider immediate referral to high level of care where there are adequate resources eg equipment/medicines to manage the case

Indications for Referral

Angina or chest pain suspected to indicate clinical instability of CAD ie Unstable Angina See section 6.4

When diagnosis is in doubt/ failed medical therapy especially if no echocardiogram available or unavailability of skilled personnel to perform transthoracic echocardiogram.

Before referral especially when high likelihood of clinical instability of stable CAD consider giving .

Aspirin 300mg (PO) stat.

AND

Clopidogrel 300mg (PO) stat

AND

Simvastatin 80mg (PO) stat

OR

Atorvastatin 80mg (PO) stat

Non-pharmacological

General Measures

• Life style modification. Refers to section of Prevention of ischaemic heart disease and atherosclerosis.

• Annual control of lipids, glucose metabolism and creatinine is recommended in all patients with known SCAD.

• A resting ECG is recommended in all patients at presentation and during or immediately after an episode of chest pain suspected to indicate clinical instability of CAD. Consider immediate referral

• A resting transthoracic echocardiogram is recommended in some patients for: a) exclusion of alternative causes of angina; b) regional wall motion abnormalities suggestive of CAD; c) measurement of LVEF for risk stratification purpose d) evaluation of diastolic function. Consider referral if no echocardiogram available or unavailability of skilled personnel to perform transthoracic