2.6.3 Other antianginal drugs
- Nicorandil has similar efficacy to other anti-angina drugs in controlling symptoms but there is little evidence about its efficacy in combination with other anti-angina drugs. However, when added to maximal therapy with other anti-angina drugs in refractory unstable angina (unlicensed indication) it may produce additional benefit.
- Nicorandil is a potassium channel activator with nitrate properties; therefore additional nitrates may not be needed.
- Nicorandil is associated with a risk of gastrointestinal ulceration, including perianal ulceration. Although mouth ulceration has long been recognised as a side-effect of nicorandil treatment, its use has more recently been associated with ulceration of any region of the gastrointestinal tract including the perianal area. The ulceration is commonly severe and, in a few patients, has led to perforation. Time to onset may vary widely. These ulcers are refractory to treatment; they respond only to withdrawal of nicorandil, which should be done only under the supervision of a cardiologist.
- It is recommended that nicorandil should only be prescribed on the advice of a specialist or by someone with a specialist interest.
- Ivabradine may be useful for the symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm, for whom heart rate control is desirable, and who have a contra-indication or intolerance for beta-blockers and rate-limiting calcium-channel blockers.
- The ‘Beautiful’ study demonstrated ivabradine safety with significant LV dysfunction, in addition to a beta blocker. With angina and impaired LV, ivabradine can be used in preference to a calcium antagonist.
- NICE has approved the use of ivabradine as a treatment option for chronic heart failure in certain patients after a four week stabilisation period on optimised standard treatments (TA267 Nov 2012)