ACS

• Most patients with ACS are not hypoxaemic and the benefits/ harms of oxygen therapy are unknown in such cases. 

• Unnecessary use of high-concentration oxygen may increase infarct size. 

• In MI and ACS, current recommendations suggest to aim at an oxygen saturation of 94–98% or 88–92% if the patient is at risk of hypercapnic respiratory failure

Resource

• Guideline for Oxygen use in Healthcare and Emergency Settings. (BTS, 2017)

• Coronary heart disease: ​Coronary heart disease (NHS Choices)

• Angina: Angina (CKS), Anti-Anginal Preparations: ​Anti-Anginal Preparations (MIMS)

• MI secondary prevention: MI secondary prevention (CKS)

• Coronary artery bypass (CABG): Coronary artery bypass (CABG) (NHS Choices)

Patients with established CVD will benefit from intensive lipid lowering with atorvastatin 80 mg, the aim being to lower LDL (low-density lipoprotein) cholesterol as much as possible. This is more cost effective than using simvastatin, and with less risk of myopathy. A lower dose of atorvastatin can be used if there is a risk of adverse effects or drug interactions.

Angina

First line treatment for angina is either a beta blocker or a calcium channel blocker. Where one group is not tolerated, the other should be tried. Where neither calcium channel blockers or beta blockers are tolerated, second line monotherapy is a long-acting nitrate, ivabradine, nicorandil or ranolazine.

If there are no issues with tolerance, but control is inadequate, second line treatment would be a dihydropyridine calcium channel blocker plus a beta blocker. Further escalation would be adding in a third drug: a long-acting nitrate, ivabradine, nicorandil or ranolazine

Resources

NICE. Stable Angina: management. CG126. 2011 (updated 2016).

RCGP. Medical management of coronary artery disease. Five minutes to change your practice. 2024.