Quality statement 3: Medical treatment before revascularisation

Quality statement

People with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary, before revascularisation is considered.

Quality measure

Structure: Evidence of local arrangements to ensure that people with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.

Process: Proportion of people with stable angina who are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.

Numerator – the number of people in the denominator prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.

Denominator – the number of people with stable angina considered for revascularisation.

What the quality statement means for each audience

Service providers ensure systems are in place to prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary for people with stable angina before revascularisation is considered.

Healthcare professionals prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered in people with stable angina.

Commissioners ensure they commission services that prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary for people with stable angina before considering revascularisation.

People with stable angina are prescribed a short-acting nitrate and 1 or 2 drugs as necessary to prevent angina before revascularisation (an operation to improve blood flow) is considered.

Source guidance

NICE clinical guideline 126 recommendations 1.3.3, 1.4.8, 1.4.9, 1.4.11, 1.4.12 and 1.5.1.

Data source

Structure: Local data collection.

Process: Local data collection. Contained within NICE audit support for management of stable angina (NICE clinical guideline 126): criteria 1, 5c, 7a and 7b.

Definitions

Prescribing 1 or 2 anti-anginal drugs as necessary

NICE clinical guideline 126 section 1.4 contains recommendations on the correct treatment when anti-anginal drugs are contraindicated, not tolerated or when symptoms are not satisfactorily controlled.

NICE clinical guideline 126 recommendation 1.4.8: If the person cannot tolerate the beta-blocker or calcium-channel blocker, consider switching to the other option (calcium-channel blocker or beta-blocker).

NICE clinical guideline 126 recommendation 1.4.9: If the person's symptoms are not satisfactorily controlled on a beta-blocker or a calcium-channel blocker, consider either switching to the other option or using a combination of the 2.[1]

NICE clinical guideline 126 recommendation 1.4.11: If the person cannot tolerate beta-blockers and calcium-channel blockers or both are contraindicated, consider monotherapy with 1 of the following drugs:

  • a long-acting nitrate or

  • ivabradine or

  • nicorandil or

  • ranolazine.

Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs.[2]

NICE clinical guideline 126 recommendation 1.4.12: For people on beta-blocker or calcium-channel blocker monotherapy whose symptoms are not controlled and the other option (calcium-channel blocker or beta-blocker) is contraindicated or not tolerated, consider 1 of the following as an additional drug:

  • a long-acting nitrate or

  • ivabradine[3]or

  • nicorandil or

  • ranolazine.

Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs.[2]



[1] When combining a calcium-channel blocker with a beta-blocker, use a dihydropyridine calcium-channel blocker, for example, slow release nifedipine, amlodipine or felodipine.

[2] Since the NICE guideline was produced, the Medicines and Healthcare products Regulatory Agency (MHRA) have published new advice about safety concerns related to ivabradine (June 2014 and December 2014) and nicorandil (January 2016).

[3] When combining ivabradine with a calcium-channel blocker, use a dihydropyridine calcium-channel blocker, for example, slow release nifedipine, amlodipine, or felodipine.