Angina
The pathways in this section are intended as a guide for initiation of the pharmacological management of Angina according to the individual patient assessment of symptoms.
NICE CG126: Stable angina management SIGN 151: Management of stable angina
Formulation as per clinical presentation. Note spray is more cost effective than tablets.
History Notes
27/05/2026
Regional formulary chapter launched.
If intolerant to betablocker or inappropriate consider diltiazem or verapamil. Modified release diltiazem should be prescribed by brand name for strengths over 60mg due to differences in bioavailability.
If the patient's symptoms are not satisfactorily controlled on a single agent treatment from step 1, then consider addition of isosorbide mononitrate, or adding amlodipine (non rate-limiting CCB) to bisoprolol.
Amlodipine is an option if CCB not already prescribed.
Do not combine ivabradine with a rate-limiting CCB (diltiazem or verapamil) as severe bradycardia and heart failure can occur.
If angina remains uncontrolled consider addition of nicorandil (if not already added) or ivabradine (an option if BP low and rate not controlled).
Do not combine ivabradine with a rate-limiting CCB (diltiazem or verapamil) as severe bradycardia and heart failure can occur.
Amlodipine is an option if CCB not already prescribed and if BP remains elevated.
Prescribing Notes:
- Refer to relevant local/national guidance for further information regarding choices of treatment.
- Beta-blockers may cause bronchospasm; use with caution and under specialist supervision in patients with a history of asthma.
- To reduce the risk of nitrate tolerance, isosorbide mononitrate immediate release tablets should be given twice daily 6-8 hours apart.
- Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. See MHRA Drug Safety Update (December 2014) Nicorandil: risk of gastrointestinal ulceration.
- Modified release diltiazem should be prescribed by brand name for strengths over 60mg due to differences in bioavailability. The most cost-effective brand for the formulation required should be prescribed.
- Ivabradine 5mg tablets are scored and can be divided into two equal doses if 2.5mg doses are required. This is more cost effective than using 2.5mg tablets.
History Notes
27/05/2026
Regional formulary chapter launched.