One of your patients has small vessel coronary disease which is not suitable for revascularization. They are still experiencing class 2 angina particularly in the evening despite bisoprolol 10 mg od. Blood pressure is 135/90 mmHg.
What would you recommend next?a. Amlodipine
NICE guidelines recommend a beta-blocker or a calcium-channel antagonist as first line with the addition of the other class as second line. Third-line agents are long-acting nitrate, iviabradine, nicornadil, or ranolazine. ESC guidelines marginally select beta-blockers over calcium-channel agonists as first line (evidence is stronger post-MI). Second line in combination with the beta-blocker is a calcium-channel blocker or long-acting nitrate. If beta-blockers are contraindicated/not tolerated any class agent can be considered in combination. Bisoprolol is long acting but atenolol 50 mg bd may be better than 100 mg od because of its shorter half-life. There is clearly blood pressure reserve for amlodipine and the patient may also benefit from improved BP control.