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.
2 min synopsisUK scopeSources checked 25 Aug 2026Clinical review pending
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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.
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.
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.
Explain the diagnosis and emergency action plan; supply short-acting GTN and demonstrate use.
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.
EmergencyPain does not follow the stable pattern
Rest/crescendo/prolonged pain, instability, or pain persisting after two nitrate doses.
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.
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.
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.