2.6 Nitrates, calcium-channel blockers & other antianginal drugs

2.6.1 Nitrates

Isosorbide mononitrate M/R                                                                                   Standard release preparations have been replaced with the following modified release (M/R) products. These should be prescribed by brand. A guide detailing how to switch from standard formulation to modified release preparations can be found here.

2.6.2 Calcium-channel blockers

Amlodipine is for angina and hypertension, has a longer duration of action and can be given once a day.  It should be prescribed generically as amlodipine.  The besilate salt should not be prescribed as this is more expensive. 

GREEN       Amlodipine (as maleate/mesilate salt only) tablets 5mg, 10mg                               

Lercanidipine or Lacidipine can be used as a  second line calcium channel blocker when amlodipine is not tolerated (e.g. where patients develop significant ankle oedema).

Diltiazem is indicated for angina and hypertension. Prescribe modified-release diltiazem by brand name to avoid confusion between different formulations.

Diltiazem (once daily preparations)

GREEN      Slozem® (Prescribe by brand name) capsules 120mg, 180mg, 240mg, 300mg   

Nimodipine is licensed only for subarachnoid haemorrhage.

Verapamil is for angina, hypertension and arrhythmias, it reduces cardiac output, slows the heart rate and may precipitate heart failure.

Nicardipine IV for use on Critical Care Unit ELHT only, where beta-blockers not tolerated 

RED           Nicardipine IV 

2.6.3 Other antianginal drugs

Nicorandil                                                                                                                                                 Nicorandil, a potassium channel activator with a nitrate component, has both arterial and venous dilating properties and is licensed for the prevention and long-term treatment of chronic stable angina pectoris. It is usually prescribed in addition to isosorbide mononitrate if symptoms remain uncontrolled.  Patients already receiving MAXIMAL therapy with two antianginal medications (e.g. calcium channel blocker and nitrates) should be referred to a specialist for further assessment.

GREEN      Nicorandil tablets 10mg, 20mg

Ivabradine                                                                                                                                                                                                  Chronic Stable Angina

• Ivabradine should only be initiated by specialists in the treatment of chronic stable angina. 
• Ivabradine has not demonstrated any increased benefits in terms of efficacy and safety over other available treatments for angina, and is considerably more expensive.
• It is recommended for symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm for whom heart rate control is desirable and for whom beta-blockers and calcium-channel blockers are inappropriate or not tolerated. Long-term protection against cardiovascular events, however, has not been demonstrated.
• Therefore patients already receiving MAXIMAL therapy with two antianginal medications (e.g. calcium channel blocker and nitrates) should be referred to a specialist for further assessment.  
• There is no evidence that addition of a third drug improves symptom control.  If a third drug (e.g nicorandil) is introduced while awaiting an outpatient appointment, its effects should be monitored and if it has no effect it should be stopped.

AMBER     Ivabradine tablets 5mg, 7.5mg                                                                          

Chronic Heart Failure (NICE TA267)

• Ivabradine should only be initiated by specialists in the treatment of chronic heart failure

AMBER shared care   Ivabradine tablets 5mg, 7.5mg

Ivabradine prior to Cardiac CT if required to lower the heart rate

RED         Ivabradine for use prior to cardiac CT when the heart rate is raised

Ranolazine

Ranolazine should only be initiated by specialists in the treatment of chronic stable angina

Ranolazine is recommended as add on therapy for symptomatic treatment of patients with stable angina whose symptomsare inadequately controlled or intolerant  of first-line antianginal therapies, nitrates and/or nicorandil, and third line ivabradine

• Ranolazine should only be initiated by specialists in the treatment of chronic stable angina
• Ranolazine is recommended as add on therapy for symptomatic treatment of patients with stable angina whose symptoms are inadequately controlled or intolerant of first-line antianginal therapies, nitrates and/or Nicorandil, and third line Ivabradine and when there are no revascularisation options available to the patient
• Patients who experience a satisfactory response (reviewed by cardiologist after 3 months) may have their care transferred to primary care

AMBER     Ranolazine m/r tablets 375mg, 500mg, 750mg                                             

Management of Stable Angina Pathway, click here. 

2.6.4 Peripheral vasodilators and related drugs

Nifedipine may be useful for reducing the frequency and severity of vasospastic attacks in Raynaud’s syndrome. Nifedipine is no longer recommended for the treatment of hypertension and angina.

GREEN      Nifedipine capsules 5mg, 10mg

Sildenafil, as an option in severe primary or secondary Raynaud’s resistant to initial therapies (calcium channel blockers). Unlicensed Use

RED           Sildenafil tablets 25mg   

NICE guidance for peripheral arterial disease (TAG 223)

Naftidrofuryl oxalate is recommended as an option for the treatment of intermittent claudication in people with peripheral arterial disease for whom vasodilator therapy is considered appropriate after taking into account other treatment options. Treatment with naftidrofuryl oxalate should be started with the least costly licensed preparation i.e. generic prescribing only.

GREEN      Naftidrofuryl oxalate capsules 100mg