Angina treatment

[LSCE]

Hello, I know I need to speak to my GP regarding this but would appreciate some advice / experiences from you lovely people please. I have had 2 x minor heart attacks, 2020 and 2021. Coronary arteries not obstructed, last angio July 2022. Medication: Atorvastatin, Nifedipine, Isosorbide mononitrate ISMN), Losartan, Aspirin. I have been experiencing very mild angina since about Sept' 2022 and discussed this at my last cardiology appointment Nov 2022. Decision: changing the times of my ISMN but cardiologist suggested I could try addition of Nicorandil if the angina persisted. However, clinic letter stated 'change' from ISMN to Nicorandil if angina persisted. However, after reading the potential side effects of Nijcorandil and being scared to stop the ISMN (though I know you can become tolerant to it) as my angina was very mild, GTN responsive, after a discussion with my GP we decided not to change meds. I continue to experience angina but now very brief episodes of neck / throat pain at rest (as experienced before my heart attacks). So I'm very aware I need to do something. Just wondering if anyone else has experience of Nicorandil or an 'alternative'. I recall Milkfairy sending a link to an algorithm of treatment for vasospastic angina, which listed his both ISMN and another medication but I cant find it.

Sorry about the long post. If you have read it all thank you x

[Milkfairy Heart Star]

Hello,

It is possible to have angina without obstructed coronary arteries.

There is growing evidence that people can experience ongoing angina following a stent or even a coronary bypass surgery.

acc.org/latest-in-cardiolog....

Possible causes are microvascular dysfunction or vasospastic angina.

I also have Raynauds Phenomenon, migraines as well as vasospastic angina. A hat trick of vasomotor disorders.

With vasospastic angina you usually experience chest pain at rest in particular during the night.

I have been taking isosorbide mononitrate and GTN patches along with Nicorandil for many years to try and help prevent my coronary vasospasms.

I take 60 mgs of ISMN at 6pm and 11pm as I usually experience most of my chestpain in the evenings and during the night.

I put 20mgs of GTN patches on at 6pm, remove them in the morning to allow a nitrate free period.

I take 30mgs nicorandil at 8am and 8pm.

Perhaps discuss with your GP changing the time at which you take your ISMN and Nicorandil?

https://academic.oup.com/eurheartj/article/41/37/3504/5867624

[LSCE in reply to Milkfairy]

Hello MIlkfairy,

I was hoping you'd be in touch. I suspect I have vasospastic angina but my consultant thinks it's an unlikely cause of my heart attacks. My symptoms always used to happen at rest, usually at night. Both my confirmed heart attacks and very severe pain, starting in my throat have occurred at rest, night / very early morning. Reynauds symptoms started after first heart attack. Microvascular angina ruled out by special angio' but they never tested for vasospastic angina. I'm fearful of stopping the ISMN as after my first HA I kept experiencing the same severe pain / HA symptoms every morning and when these increased to several times a day so I ws instructed by my GP to go to A&E. Mildly elevated troponin, sent home with ISMN which almost stopped the HA like episodes for 4 months. Hence, my fear of stopping it. Thank you so much for the information. I'll discuss the option of continuing ISMN whilst adding in the Nicorandil.

[Milkfairy Heart Star in reply to LSCE]

Another thought.

It might be worth asking your GP or Cardiologist to consider a different calcium channel blocker, Diltiazem rather than Nifedipine?

Good luck, I hope you can stabilise your symptoms.

[LSCE in reply to Milkfairy]

Once again many thanks for your advice. 🤞🤞

[OzWA21]

I'm not a cardiologist, just a patient but my vasospastic angina / Nifedipine experience is that I started with Vasocardol and then switched to Nifedipine (30mg once daily) on physician advice. After approx 1 year I felt Nifedipine dose was insufficient so Cardiologist had me on Nicorandil plus Nifedipine but after a week of constant nausea the Nifedipine dose was doubled and the Nicorandil was stopped. I also take a beta blocker (Metoprolol) as there is a body of evidence to suggest this is necessary when taking Nifedipine to control blood pressure and a small statin dose (5mg) for cholesterol management.

[LSCE]

Hello OzWA21, thank you for sharing your experience. I'm on 10mg Nifedipine twice a day. Tried upping the dose and blood pressure dropping really low, which of course might happen with the addition of Nicorandil. Also on losartan for BP. Atorvastatin 80 mg. Spoke to my GP yesterday, won't change anything, said I must be under instruction and supervision of my cardiologist despite it being suggested in my last clinic letter. My next cardiologist appointment is June. GP told me to try and get an earlier appointment. Unlikely as It was cancelled from 03/04/23 to 03/06/23. I might just try the Increased Nifedipine again as that was also suggested previously and keep an eye on my BP. Thank you once again for your reply. Really appreciated.