Refractory Stable Angina — RACP Adult Medicine MCQ

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ModerateCardiologyRefractory Stable AnginaRACP Adult Medicine

A 60-year-old man with stable angina on aspirin, atorvastatin, bisoprolol, and perindopril has persistent exertional angina despite heart rate control to 58 bpm. His BP is 125/70 mmHg. What anti-anginal agent should be added?

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Correct answer: B — Add nicorandil

For stable angina with persistent symptoms despite optimal beta-blocker and ACEi/ARB therapy, a second-line anti-anginal should be added. Options include calcium channel blockers (amlodipine or diltiazem – but avoid combination of beta-blocker + diltiazem/verapamil), long-acting nitrates (isosorbide mononitrate – ensure a nitrate-free interval), nicorandil (potassium channel opener + nitrate), or ranolazine (inhibits late sodium current). Ivabradine reduces heart rate but his HR is already 58 bpm (target is >70 bpm for ivabradine). Choice depends on BP (avoid additional vasodilators if hypotensive), heart rate, and comorbidities.

Reference: eTG – 2025 – Cardiovascular; ESC – 2024 – Chronic Coronary Syndromes