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20.3 Stable Coronary Artery Disease (SCAD) | Ischemic Heart Disease (IHD)

Table of Contents

Mostly from clinical history characterized by chest pain due to myocardial ischaemia usually inducible by exercise, emotion or other stress and reproducible, relieved by rest but may occur spontaneously and stable in nature. Especially when occurs in high risk patient9, 10.

Non-Pharmacological Treatment

General Measures

  • Life style modification. See section 20.1 above Prevention of ischaemic heart disease and atherosclerosis.
  • Annual control of lipids, glucose metabolism and creatinine is recommended in all patients with known SCAD.
  • A resting ECG is recommended in all patients at presentation and during or immediately after an episode of chest pain suspected to indicate clinical instability of CAD. Consider immediate referral 9,10.
  • A resting transthoracic echocardiogram is recommended in some patients for:
  • a) exclusion of alternative causes of angina; b) regional wall motion abnormalities suggestive of CAD; c) measurement of LVEF for risk stratification purpose d) evaluation of diastolic function. Consider referral if no echocardiogram available or unavailability of skilled personnel to perform transthoracic 9,10.

Pharmacological Treatment

A: Aspirin soluble 75 – 100mg daily oral. (long-term prophylaxis for arterial thrombosis)

AND

C: Isosorbide mononitrate 10mg/20mg twice daily oral, or Isosorbide dinitrate 20mg/40mg twice daily oral preferably at 8:00 and 14:00 hours for both medicines to provide a nitrate free period to prevent tolerance.

If nitrates cannot be tolerated especially due to nitrate induced severe headache consider stepwise adding other anti-angina medicines below;

Add stepwise other anti-angina medicines

Step 1: add ß-blocker if not contraindicated eg

B: Atenolol12.5/25mg daily oral

OR

D: Metoprolol 25/50mg daily oral.

If a ß-blocker cannot be tolerated or is contraindicated, consider long acting calcium channel blocker.

Step 2 adds long acting calcium channel blocker.

D: Verapamil 30mg 2–3 times daily oral

OR

D: Diltiazem 30mg 2–3 times daily oral, if suspects Prinzmetal Angina.

Key Note:

  • All patients with stable chronic angina are high-risk for cardiovascular events, should initiate lipid lowering medicines (HMGCoA reductase inhibitors); See Section 20.2 management of dyslipidemias
  • Therapy requires good initial evaluation, ongoing support for patients and continuous evaluation to ensure compliance. Therapy should be initiated together with appropriate lifestyle modification and adherence monitoring.
  • Consider immediate referral to high level of care where there are adequate resources eg equipment/medicines to manage the case

Indications for Referral

  • Angina or chest pain suspected to indicate clinical instability of CAD ie Unstable Angina See section 4
  • When diagnosis is in doubt/ failed medical therapy especially if no echocardiogram available or unavailability of skilled personnel to perform transthoracic echocardiogram.

Before referral especially when high likelihood of clinical instability of stable CAD consider giving

A: Aspirin 300mg (PO) stat.

AND

C: Clopidogrel 300mg (PO) stat

AND

C: Simvastatin 80mg (PO) stat

OR

C: Atorvastatin 80mg (PO) stat

The codes will be shown below

Seconds
First: 170598
Seconds
Second: 180198

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