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Home Formulary 2.0 Cardiovascular System 2.6 Nitrates, calcium-channel blockers and other antianginal drugs 2.6.3 Other antianginal drugs

2.6.3 Other antianginal drugs

These drugs are not first line agents and should be reserved for the indications outlined.

NICE CG126 on the management of stable angina advises that if the person cannot tolerate beta-blockers and calcium channel blockers, or both are contraindicated, monotherapy with one of the following drugs can be considered:

The decision on which drug to use should be based on comorbidities, contraindications, the person’s preference and drug costs.

(i) Ivabradine

General Notes ivabradine

Heart Failure

  • NICE recommend that ivabradine, in combination with standard therapy including a beta-blocker (unless contraindicated or not tolerated), or when beta-blocker therapy is contraindicated or not tolerated, is an option for treating New York Heart Association (NYHA) class 2 to 4 stable heart failure in patients who
    • Have a left ventricular ejection fraction of ≤ 35% and
    • Are in sinus rhythm with a heart rate of ≥ 75 beats/min
  • Ivabradine should be initiated only by a heart failure specialist after 4 weeks of stable optimal standard therapy; monitoring and dose titration should be carried out by heart failure specialist, or a GP with a specialist interest in heart failure, or by a heart failure specialist nurse.

Angina

  • Ivabradine should only be initiated by specialists for angina as per NICE CG126 Management of Stable Angina.
  • Treatment with ivabradine should be discontinued if there is no improvement in symptoms of angina within 3 months.

Off-label use

Ivabradine is sometimes used by specialists to manage postural orthostatic tachycardia syndrome (POTS) or inappropriate sinus tachycardia with initiation by specialist in secondary care.

Cautions

  • Ivabradine may be associated with bradycardia, atrial fibrillation, and other cardiovascular risks:
    • Only start ivabradine in adults with normal sinus rhythm if the resting heart rate is at least 70 beats per minute.
    • Do not prescribe ivabradine with verapamil, diltiazem, or strong CYP3A4 inhibitors
    • See MHRA for further details

(ii) Nicorandil

General Notes nicorandil

  • Nicorandil should be reserved for the treatment of stable angina in patients where treatment with rate-limiting agents, nitrates or dihydropyridine CCBs are ineffective, contra-indicated or not tolerated.
  • Gastrointestinal ulcerations, skin and mucosal ulceration have been frequently reported with nicorandil. These are refractory to treatment and most only respond to withdrawal of nicorandil treatment. If ulcerations develop, nicorandil should be discontinued.
  • If prescribed, quantities should be in multiples of 10 to ensure stability of the product.

(iii) Ranolazine

General Notes ranolazine

  • Ranolazine is indicated for treatment of stable angina in patients inadequately controlled or intolerant of first-line antianginal therapies.
  • Ranolazine is sometimes used in patients with microvascular angina (ESC 2024).
  • Ranolazine inhibits myocardial late sodium current (hence reduces calcium influx) but does not affect heart rate or BP, thus may be particularly useful in patients with low BP and/or low heart rate.

Cautions

  • Caution in patients with body weight <60kg or borderline renal function (avoid if eGFR less than 30mL/minute/1.73m2).
  • Ranolazine is largely metabolised by the CYP3A4 system thus there is a potential for serious drug interactions, especially at higher doses (see BNF).

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