Chronic coronary syndromes

Red Flags

Crescendo angina (rest pain or new-onset within 2 weeks) — likely acute coronary syndrome, not chronic; immediate ED triage^[1]
Syncope on exertion plus chest pain — exclude severe aortic stenosis or critical proximal coronary disease before stress testing^[1]
Heart failure symptoms or LVEF <50% with angina — high event risk; expedite invasive evaluation^[1]
Known CCS with new typical chest pain unresponsive to nitrates — re-evaluate for plaque rupture or progression^[1]

Cardiac rehabilitation and lifestyle^[1]
Structured supervised exercise programme, Mediterranean-style diet, smoking cessation, weight reduction, alcohol moderation, annual influenza vaccination

Drug	Class	Adult	Paediatric	Notes
Aspirin^[1]	Antiplatelet	75–100 mg PO once daily	—	Lifelong unless contraindicated. Clopidogrel 75 mg daily is an alternative if aspirin-intolerant
Atorvastatin^[1]	HMG-CoA reductase inhibitor (high-intensity statin)	40–80 mg PO once daily	—	LDL-C goal <55 mg/dL (1.4 mmol/L) for established ASCVD; add ezetimibe and PCSK9 inhibitor if not at goal
Metoprolol succinate^[1]	Beta-blocker (cardioselective)	25–200 mg PO once daily, titrate to heart rate 55–60 bpm	—	First-line antianginal. Bisoprolol or carvedilol are interchangeable
Amlodipine^[1]	Calcium channel blocker (DHP)	5–10 mg PO once daily	—	Add when beta-blocker monotherapy insufficient or contraindicated; first-line in vasospastic angina
Glyceryl trinitrate (sublingual)^[1]	Short-acting nitrate	0.3–0.6 mg sublingually for acute angina episode; repeat every 5 min up to 3 doses	—	All CCS patients should carry a sublingual nitrate. Seek emergency care if pain unrelieved after 3 doses
Empagliflozin^[1]	SGLT2 inhibitor	10 mg PO once daily	—	Class I in CCS with diabetes, heart failure, or CKD per 2024 update

Aspirin^[1]

Antiplatelet

Lifelong unless contraindicated. Clopidogrel 75 mg daily is an alternative if aspirin-intolerant

Atorvastatin^[1]

HMG-CoA reductase inhibitor (high-intensity statin)

LDL-C goal <55 mg/dL (1.4 mmol/L) for established ASCVD; add ezetimibe and PCSK9 inhibitor if not at goal

Metoprolol succinate^[1]

Beta-blocker (cardioselective)

First-line antianginal. Bisoprolol or carvedilol are interchangeable

Amlodipine^[1]

Calcium channel blocker (DHP)

Add when beta-blocker monotherapy insufficient or contraindicated; first-line in vasospastic angina

Glyceryl trinitrate (sublingual)^[1]

Short-acting nitrate

Adult: 0.3–0.6 mg sublingually for acute angina episode; repeat every 5 min up to 3 doses
Paediatric: —

All CCS patients should carry a sublingual nitrate. Seek emergency care if pain unrelieved after 3 doses

Empagliflozin^[1]

SGLT2 inhibitor

Class I in CCS with diabetes, heart failure, or CKD per 2024 update

Carry sublingual nitrate at all times; if chest pain lasts longer than 10 minutes despite 3 doses, call emergency services — this may be a heart attack^[1]
Take aspirin and statin every day for life — these reduce the chance of heart attack and death even when you feel well^[1]
New chest pain that wakes you from sleep, occurs at rest, or is worse than your usual angina — same-day medical review^[1]

Crescendo angina, rest pain, or chest pain unresponsive to 3 doses of sublingual nitrateEmergency department for ACS evaluation^[1]
High RF-CL likelihood (>50%) with positive functional test or CCTA showing left main / proximal LAD disease or 3-vessel diseaseCardiology for invasive coronary angiography and revascularisation evaluation^[1]
Persistent angina despite optimised dual antianginal therapyCardiology for invasive evaluation or specialist refractory-angina clinic^[1]
ANOCA/INOCA suspected: typical angina with non-obstructive CCTA or no obstructive disease at angiographySpecialist with capacity for coronary functional testing (acetylcholine challenge, CFR, IMR)^[1]

Diagnosis and long-term management of stable coronary disease, including ANOCA/INOCA and ischaemic heart disease without recent ACS.