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]
First-line treatment
Interventions
- Cardiac rehabilitation and lifestyle[1]Structured supervised exercise programme, Mediterranean-style diet, smoking cessation, weight reduction, alcohol moderation, annual influenza vaccination
First-line drug therapy
| 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
- Adult
- 75–100 mg PO once daily
- Paediatric
- —
Lifelong unless contraindicated. Clopidogrel 75 mg daily is an alternative if aspirin-intolerant
Atorvastatin[1]
HMG-CoA reductase inhibitor (high-intensity statin)
- Adult
- 40–80 mg PO once daily
- Paediatric
- —
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)
- Adult
- 25–200 mg PO once daily, titrate to heart rate 55–60 bpm
- Paediatric
- —
First-line antianginal. Bisoprolol or carvedilol are interchangeable
Amlodipine[1]
Calcium channel blocker (DHP)
- Adult
- 5–10 mg PO once daily
- Paediatric
- —
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
- Adult
- 10 mg PO once daily
- Paediatric
- —
Class I in CCS with diabetes, heart failure, or CKD per 2024 update
Safety-net
- 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]
Referral criteria
- 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]
Clinical summary
Diagnosis and long-term management of stable coronary disease, including ANOCA/INOCA and ischaemic heart disease without recent ACS.