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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Stable angina and chronic coronary syndrome

Cardiology · UK scope · Sources checked 25 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Treat as possible acute coronary syndrome and arrange emergency transfer if pain is new at rest, rapidly worsening, haemodynamically compromising, lasts more than 15 minutes, or persists 5 minutes after a second short-acting nitrate dose. A normal ECG or relief with GTN does not exclude ACS.

Synopsis

Recognise stable myocardial ischaemia, exclude acute coronary syndrome, start symptom and event-prevention treatment, and refer appropriately for anatomical assessment or revascularisation. Drug doses below are named UK licensed examples unless explicitly described as a NICE recommendation.

  • Typical angina has all three NICE features: constricting discomfort in the chest/neck/shoulders/jaw/arms, precipitation by exertion, and relief by rest or GTN within about 5 minutes; two features is atypical and zero or one is non-anginal.
  • For new typical or atypical stable chest pain, NICE first-line anatomical testing is 64-slice-or-above CT coronary angiography; do not use exercise ECG to diagnose or exclude angina in someone without known CAD.
  • Give a short-acting nitrate and a written action plan: repeat after 5 minutes; if pain remains 5 minutes after the second dose, call an ambulance.
  • First-line regular symptom treatment is either a beta-blocker or calcium-channel blocker; review in 2–4 weeks and titrate to the maximum tolerated dose.
  • If combining a beta-blocker with a calcium-channel blocker, choose a dihydropyridine such as amlodipine, felodipine or modified-release nifedipine, not verapamil or diltiazem.
  • Consider aspirin 75 mg daily after individual bleeding assessment, offer high-intensity statin therapy for established CVD, and treat smoking, blood pressure, diabetes, activity and diet.
  • Long-acting nitrate, ivabradine, nicorandil or ranolazine are NICE alternatives when both first-line classes are contraindicated or not tolerated, or selected add-ons when the other first-line class cannot be used.
  • Offer angiography and discuss PCI or CABG when symptoms remain uncontrolled on optimal medical therapy; do not simply add a third antianginal except while awaiting revascularisation or when revascularisation is inappropriate or declined.

    • Key red flags

    Acute coronary syndrome

    Pain at rest, abrupt crescendo symptoms, episodes lasting over 15 minutes, diaphoresis, vomiting, breathlessness or haemodynamic instability require an ACS pathway.

    Dangerous mimics

    Consider aortic dissection, pulmonary embolism, pneumothorax, severe aortic stenosis and hypertrophic cardiomyopathy; severe tearing pain, pulse deficit, hypoxia, syncope or a harsh murmur changes the pathway.

    Investigation priorities

    01
    Immediate history, examination and 12-lead ECGFirst step

    Classify typicality, identify ACS or an alternative cardiac diagnosis, and record baseline conduction/rhythm before rate-limiting treatment.

    02
    CT coronary angiographyFirst line

    NICE first-line test for typical/atypical angina, or non-anginal pain with resting ST-T changes or Q waves.

    Management branches

    InitialLikely stable angina while testing proceeds

    Predictable stable symptoms without ACS red flags.

    1. Explain the diagnosis and emergency action plan; supply short-acting GTN and demonstrate use.
    2. Consider aspirin 75 mg once daily after allergy, bleeding and comorbidity assessment; offer atorvastatin 80 mg once daily for established CVD unless interactions, adverse-effect risk or preference justify a lower dose.
    3. Offer either a beta-blocker or a calcium-channel blocker, taking account of comorbidity, contraindications and preference.
    4. Address smoking, BP, diabetes, weight, activity and cardiac rehabilitation-style education; do not use supplements as event-prevention therapy.
    EmergencyPain does not follow the stable pattern

    Rest/crescendo/prolonged pain, instability, or pain persisting after two nitrate doses.

    1. Stop exertion, sit down and take the prescribed short-acting nitrate.
    2. Repeat after 5 minutes; call an ambulance if pain is still present 5 minutes after the second dose.
    3. Use the NICE acute chest-pain/ACS pathway, including urgent ECG and troponin; do not delay transfer for diagnostic testing.

    Key medicines

    Glyceryl trinitrate sublingual spray — licensed product example400 micrograms (1 spray) under the tongue at onset; a second dose after 5 minutes under the NICE action plan. The cited SmPC permits 1–2 sprays and repeat at 5-minute intervals up to 3 sprays (1.2 mg) in 15 minutes, but the patient must call an ambulance if pain remains 5 minutes after the second dose. For prevention, 1–2 sprays 2–3 minutes before a predictable trigger.Sit down before dosing. Avoid with PDE5 inhibitors or riociguat; caution hypotension, hypovolaemia, severe aortic stenosis and hypertrophic obstructive cardiomyopathy. Headache and dizziness are common.
    Bisoprolol — licensed stable-angina exampleStart 5 mg by mouth once daily; usual 10 mg once daily; maximum 20 mg once daily, titrated to symptoms, pulse and BP.Avoid unpaced second/third-degree AV block, marked bradycardia, cardiogenic shock or acute decompensated HF; use caution in asthma/COPD and peripheral vascular disease. Do not stop abruptly.
    Open full textbook →Answer 2 questionsCardiology check
    Sources and review status9 sources · checked 25 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 25 Aug 2026; clinical approval remains outstanding.

    • NICE CG126: Stable angina—recommendationsCore UK treatment and revascularisation pathway.
    • NICE CG95: Recent-onset chest pain—recommendationsClinical classification, ACS red flags and diagnostic testing.
    • NICE NG238: Cardiovascular disease risk reduction—recommendationsHigh-intensity statin and lipid targets.
    • GTN 400 micrograms/spray SmPCProduct-specific licensed dosing and contraindications.
    • Bisoprolol SmPCProduct-specific stable-angina dosing.
    • Amlodipine SmPCProduct-specific stable-angina dosing.
    • Ranolazine SmPCProduct-specific add-on dosing and safety.
    • MHRA: Ivabradine in symptomatic angina—cardiac risk minimisation
    • MHRA: Nicorandil now second-line—ulcer complications

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom