Acute attacks are managed by glyceryl trinitrate. This is usually administered in the form of a sublingual spray. It provides rapid symptomatic relief but effects only last for 20 to 30 minutes. When an angina attack occurs, one or two sprays should be sprayed under the tongue. This is repeated every 5 minutes until symptoms subside. If after 15 minutes symptoms still remain, patients should ring 999 for immediate assistance.
If attacks occur more than twice a week, regular drug treatment should be introduced in a step-wise manor starting with either a beta blocker or a calcium channel. If symptoms are still poorly controlled a combination of these two agents can be used. If this combination cannot be tolerated or is inappropriate due to contra-indications or interactions then a long acting nitrate, ivabradine, nicorandil or ranolazine can be considered.
Nitrates are potent vasodilators that can be used for prophylaxis of angina. They are available in modified release preparations which have a duration of action of up to 12 hours.
Many people who take nitrates will develop tolerance as a result of regular usage. To overcome this patients should maintain a nitrate-free period each day by taking the modified release preparations 8 hours apart instead of 12 hours. Patients receiving nitrate treatment in the form of transdermal patches should remove them for several consecutive hours each day.