Raavi as you know there’s been a lot of changes over the past few years really from the european society of cardiology through to nice with an increased emphasis on management within primary care after revascularization has been considered within the hospital setting and also we have a much greater range of drugs that are available for the management of stable angina
From your perspective have you noticed these changes and have you had any difficulties with with ongoing management of these patients good question you put we do you know as we see these patients we consider angina as a possible cause often it’s obvious it is angina we refer them on for confirmation and consideration of revascularisation or cabbage as appropriate
And we leave the initial management obviously immediate management we start off with you know preventive therapy hopefully they already on that by the time they see you but in terms of when they come back to us after revascularisation or further investigations yeah i think we have we are seeing some changes in current management may be interesting to see you know
Whether this is this this trend is so widespread be useful to see the effect of that as well yes i mean i think you’re right i think the road of revascularization for stable angina has been looked at and we we know that there are groups of patients that benefit prognostically but we know that there are large numbers of patients with anatomical quorum disease who
Can be as well treated with medical therapy also of course as we have an increasing aging population we have a larger number of people with more complex medical problems for whom we vaster ization may carry a significant risk so again we’re left with with options with with medical therapy i think from our perspective the drugs which we now have prognostic impact
Our statins and ace inhibitors and that’s always my first priority and then of course we have a range of drugs that we can offer patients once we’ve looked at where the revascularization is in the patient’s best interest and of course patient choice is very important in terms of whether they want to proceed with revascularization in the mode and we of course use
Anatomical information with functional information stress echo perfusion scanning most of that will be done within the hospital setting and then once we’ve settled with the patient on a strategy plan we send them back to yourself which which which drugs do you tend to use first slide rule of hopefully considered all the preventive measures primary prevention
Secondly proper salute as first-line and obviously for specific anti and journals beta blockers as long as it no contraindications diverse and often calcium channel clock yes either or both often yes they’re you know they’re already on combined by the tactical maneuver sometimes but if not intake presenting back to us frequent enough whilst they’re waiting to see
We will provided there are no contraindications provided the dynamically stable will here probably adding the other very good yes i mean and it is interesting for nearly twenty years we had the same drugs only those drugs where calcium blockers we have beta blockers in all the nitrates both effective all of them effective but of course some are not tolerated by
Patients and some of them need more drugs we’ve now got some new drugs on the market we have other rate lowering drugs such as i’ve a protein which requires some degree of heart rate monitoring but can be tolerated by some and we have this new class of drug and ranolazine the late sodium inhibitor which the data suggests is effective for angina a nice of position
This is a second night drug to consider once we’ve tried the conventional drugs from your perspective in in terms of a new drug being required what are your concerns or fears and what are you looking for from the drug interesting obviously new drug you obviously were a long-term safety obviously a fixie probably won’t be on the market if it’s not a vacation so you
Hope but safety is the main concern and monitoring yes what monitoring am i required to do in primary care especially recently be getting increasing requests from our local unit do you know local trust to provide ranolazine and yes i mean i’ve taken that on board and actually even though it’s not on their farm formulary as yet which but i promise that it will
Be i have prescribed it on some of my patients and i’ve seen good results in some of those in terms of my concerns monitoring you know when do i start yes what do i look for one started and long-term evidence you know is there is it actually just a symptom relief or has he got a endpoint data yeah like ace inhibitors do your meter blockers do you have failure for
Example yes no i think that’s that’s very important because i think in terms of a new drug there’s always a slight apprehension to starting i think the first thing that seems to be coming out very clearly is that it’s effective at treating angina both in terms of symptom relief lower gt and consumption and if you objectively evaluate patients on a treadmill they
Can walk for further so we know it’s effective i mean certainly my advice is always to try the traditional drugs first as per nice guidance but then this drug should be considered in the second line group it’s advantage i think from a primary care perspective is that it doesn’t require any specific monitoring in terms of blood tests or heartrate assessments which
I think it’s important because i think practical follow up with these patients isn’t presumably not very easy from your side and i think the other thing is there are very few drug interactions very few serious side effects if any and i think that the other advantage is that it’s hemodynamic neutral it can be used in heart failure a lot of patients with difficult
To treat and joy and a half heart failure and it can be used with a neutral effect on the patient it doesn’t know a blood pressure it doesn’t cause a predisposition to worsening heart phone anything that’s very important so i think the lack of sort of objective monitoring is useful i think the groups that i would always look out for and it’s worthwhile checking
With the hospital our patients who have significant liver disease and renal disease having their patients that i think one has to have have a degree of caution and i think also as with so many drugs we use the patients over 75 have a higher side-effect profile so i usually start very cautiously in that group at a smaller dose of 375 milligrams twice a day often
I find in the elderly there is a balance between side-effects and benefits and i mean and i can’t be quite pleased to keep them on that dose if it relieves their symptoms if they remain symptomatic after around three to four weeks i will increase the dose to 500 milligrams twice a day i find that in the vast majority of those patients that’s the only dose we need
In younger patients we can of course go higher to 750 milligrams i think in the elderly i would always start at a lower dose and and not feel obliged to increase unless their symptoms will dictate just from my perspective when i’ve started patients and ranolazine i start started several and i haven’t yet come across much in terms of side effects but are they any
Particular obviously i’ve been told that these are common are in elderly in age group but is there anything specific i need to be concerned about looking out for worried about what are the common ones that you see the good news about ranolazine is that it is very well tolerated and has very few significant side effects the main side effects to look out for and to
Warn patients about our gastrointestinal they’re usually quite minor nausea vomiting constipation some people may also feel dizzy and the important thing to let the patients know about is that these effects usually only last for the first two weeks and certainly the clinical data would suggest drug withdrawal because of these side effects is very rare particularly
Younger patients in the over 75 the side effect profile as ever in this group is slightly worse with gastrointestinal disturbance are usually fine starting at a lower dose of 375 milligrams twice in this group they can usually see through any minor side effects that they will have okay are there any particular drugs i should avoid and i think it’s unlisted content
Occasions yes you know many of these patients that we see in primary care often put them on antibiotics yes i think the first thing i always say to anyone in primary care and indeed secondary care and tertiary care is that whenever you have a new drug i think it’s always safe to check before you prescribe but but but the advantage with rinona seen it’s been used
In combination with other anti anginal drugs very safely so we know it can be used in combination with those drugs it can be used safely with ace inhibitors and statins the mainstay of treatment for stable angina in terms of specific drugs there’s a very there’s a small number of antiarrhythmics where you shouldn’t use it and the biggest group of drugs are the
So-called class a one a drugs for a written treatment quinidine but this is relatively rare and and i would suggest there’s a practical advice if a patient is on a anti-arrhythmic drug it may be worthwhile just discussing your local cardiologist cuz there’ll be such a small number the other more common drugs within primary care are certain antibiotics particularly
Erythromycin and clarithromycin because of the way in which the drug works it can interact with those drugs so i would avoid in patients on these antibiotics the reality is that only beyond these antibiotics for a short duration anyway and then you can stop and then start after there and the other important group of primary care are antifungal drugs particularly
Ketoconazole so i think if you’re any of those drugs i would finish your course before starting on the magazine write as president because of the cyp yes exactly right okay redo that thank you thank you very much
Transcribed from video
Management of angina and role of Ranolazine – NICE Guidelines /Part 1 By Cardio Debate
