I20.9
DESCRIPTION
Characteristic chest pain (burning or heavy discomfort behind the sternum), of duration < 15 minutes, due to myocardial ischaemia, usually occurring on exercise and relieved by rest.
GENERAL MEASURES
Life style modification. See: Prevention of ischaemic heart disease and atherosclerosis.
MEDICINE TREATMENT (Doctor initiated)
Long-term prophylaxis for thrombosis:
- Aspirin, oral, 150 mg daily.
AND
Relief of angina
- Nitrates, short acting e.g.:
- Isosorbide dinitrate, sublingual, 5 mg.
- May be repeated if required at 5 minute intervals for 3 or 4 doses.
- Instruct patients to keep the tablets in the airtight and lightproof container in which they are supplied.
- Instruct patients that nitrates are not addictive.
- Instruct patients to use prophylactically, before activities which may provoke angina.
AND
Step 1
- Beta-blocker
- Atenolol, oral, 50–100 mg daily.
- Titrate to resting heart rate of approximately 60 beats/minute.
- Atenolol, oral, 50–100 mg daily.
If ß-blocker cannot be tolerated or is contraindicated, consider long-acting calcium channel blocker.
Step 2
ADD
- Long acting calcium channel blocker e.g.:
- Amlodipine, oral, 5 mg daily.
Step 3
ADD
- Isosorbide mononitrate, oral, 10–20 mg twice daily.
OR
- Isosorbide dinitrate, oral, 20–30 mg twice daily.
- Taken at 8:00 and 14:00 hours for both medicines in order to provide a nitrate free period to prevent tolerance.
- Modify for night shift workers.
Angina is a high-risk condition for cardiovascular disease and is an indication for a statin.
- HMGCoA reductase inhibitors (statins), e.g.:
- Simvastatin, oral, 40 mg at night.
Patients on protease inhibitor:
- Atorvastatin, oral, 10mg at night.
Patients on amlodipine (and not on a protease inhibitor):
- Simvastatin, oral, 10-20mg at night.
If patient complains of muscle pain:
Reduce dose to:
- Simvastatin, oral, 20 mg at night.
OR
Refer for further management.
REFERRAL
- When diagnosis is in doubt.
- Failed medical therapy.