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Practice Therapeutics

Novel drugs for treating angina

BMJ 2013; 347 doi: (Published 09 September 2013) Cite this as: BMJ 2013;347:f4726
  1. Daniel A Jones, research fellow12,
  2. Adam Timmis, professor of clinical cardiology12,
  3. Andrew Wragg, consultant cardiologist12
  1. 1NIHR Cardiovascular Biomedical Research Unit, London E2 9JX, UK
  2. 2London Chest Hospital, Barts Health NHS Trust, London, UK
  1. Correspondence to: A Timmis adamtimmis{at}
  • Accepted 12 July 2013

Angina is the pain caused by myocardial ischaemia, usually as a result of obstructive coronary artery disease. Although angina typically presents as chest pain on exertion, patients can also present with atypical symptoms such as shortness of breath without pain. Guidelines1 2 recommend initial treatment with one or two antianginal drugs, plus aspirin, and a statin for secondary prevention of cardiovascular disease. If symptoms are not adequately controlled, coronary revascularisation by percutaneous coronary intervention or coronary artery bypass surgery is often effective.1 2

The antianginal drugs recommended for initial treatment are β blockers and calcium channel blockers, which reduce myocardial ischaemia by heart rate reduction and vasodilatory mechanisms, respectively. Either or both of these drug classes should be prescribed, together with a short acting nitrate for prompt alleviation of angina attacks (figure) However, if these drugs are not tolerated, are contraindicated, or fail to correct symptoms, alternative antianginals are available, such as oral nitrates and newer antianginal drugs, which are the subject of this review. Although oral nitrates have been used for many years to treat stable angina, the National Institute for Health and Care Excellence concluded that evidence related to their efficacy was insufficient and hence advised that oral nitrates should be used as second line therapy after β blockers and calcium channel blockers. NICE also concluded that evidence was insufficient to make a firm recommendation about the choice of second line antianginals, which we present here in alphabetical order.

Treatment algorithm for novel antianginal drugs. Modified from National Institute for Health and Care Excellence1

Novel antianginal drugs

Alternative antianginal drugs include older less familiar ones such as nicorandil, which has been available for the past 20 years, and newer antianginal drugs such as ivabradine and ranolazine. Also available in many countries (not the United Kingdom) is trimetazidine. …

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