# Chronic ischaemic heart disease - Category: acute - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary - cardiovascular.pdf, Atorvastatin monograph (chapter PDF p207) · Egyptian National Drug Formulary - cardiovascular.pdf, Clopidogrel monograph (chapter PDF p119) · Egyptian National Drug Formulary - cardiovascular.pdf, Isosorbide mononitrate monograph (chapter PDF p71) · Gillen C, Shams P, Goyal A. Stable Angina. [Updated 2026 Jun 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID NBK559016. - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - cardiovascular.pdf, Atorvastatin monograph (chapter PDF p207) - Egyptian National Drug Formulary - cardiovascular.pdf, Clopidogrel monograph (chapter PDF p119) - Egyptian National Drug Formulary - cardiovascular.pdf, Isosorbide mononitrate monograph (chapter PDF p71) - Gillen C, Shams P, Goyal A. Stable Angina. [Updated 2026 Jun 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID NBK559016. ## Treatment metadata - Atorvastatin — oral.solid - Isosorbide-5-mononitrate — oral.solid - Clopidogrel — oral.solid ## Complete treatment card ```text CHRONIC ISCHAEMIC HEART DISEASE Sources: Egyptian National Drug Formulary - cardiovascular.pdf, Atorvastatin monograph (chapter PDF p207) · Egyptian National Drug Formulary - cardiovascular.pdf, Clopidogrel monograph (chapter PDF p119) · Egyptian National Drug Formulary - cardiovascular.pdf, Isosorbide mononitrate monograph (chapter PDF p71) · Gillen C, Shams P, Goyal A. Stable Angina. [Updated 2026 Jun 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID NBK559016. Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (12) - Angina: discomfort building gradually in the chest, mainly behind the breastbone - Brought on by physical effort or emotional upset, and at rest in acute coronary syndrome - The pain often travels to left arm, neck, jaw, teeth or ear - Breathlessness, nausea and dizziness commonly go with the chest discomfort [breathlessness · chest pain · dizziness · nausea] - The quality varies: heaviness, pressure, squeezing or tightness, eased by rest or nitroglycerin - Atypical pain: upper abdomen or back, or a burning, stabbing or indigestion-like feeling [indigestion] - Women may report breathlessness, tiring easily and back pain [back pain · breathlessness] - Sometimes the only complaint during ischaemia is pain in the face or skull [facial pain · ischaemia] - An angina equivalent: no chest discomfort, but breathlessness on effort that limits what the patient can do [breathlessness] - Stable angina lasts minutes, not seconds or hours, after a predictable amount of effort, and rest relieves it - Red flag for unstable angina: pain on less effort, lasting longer, or getting worse - It can be entirely silent, the underlying atherosclerosis having built up over decades SIGNS - what you find (9) - On inspection look for acute distress, raised neck veins and swollen ankles [leg swelling · raised JVP] - On palpation feel for a fluid thrill or a heave, and grade any ankle swelling or neck vein filling [ascites · leg swelling] - Listen over all four heart areas, and over the lungs with attention to the bases - Chest pain that the examiner can reproduce by pressing, or that shifts with breathing, or that the patient pinpoints, argues against ischaemia [chest pain] - Older age, female sex and diabetes are the usual setting for an angina equivalent, and for silent ischaemia [ischaemia] - Symptoms appear only once a coronary artery is narrowed by half or more - Atypical pain is misdiagnosed more often, and carries triple the death rate of classic angina - Between 2 and 5 in every 100 heart attacks sent home from the emergency room do badly - That miss usually happens when there is no chest pain and no ST elevation on the tracing TESTS (12) - Typical angina means all three: pain behind the breastbone, brought on by effort or emotion, relieved by rest or nitroglycerin - Start with history, examination and a baseline ECG looking for ischaemia or an old infarct - Acute coronary syndrome shows ST and T wave changes, and rhythm disturbances - In long-standing disease the tracing may show axis shift, bundle branch block or thickened ventricle - A silent infarct is sometimes found by chance as abnormal Q waves on a routine tracing - Everyone with stable disease needs an echo, since ventricular dysfunction changes management - Echo may show regional wall motion change matching an artery territory, from ischaemia or an old infarct - Routine bloods: lipids, HbA1c and kidney function - Troponin and natriuretic peptide are not needed to make the diagnosis, though they help in the right setting - Stress testing stops if angina appears or the tracing shifts, particularly in the ST segments - On a treadmill the target is 85% of the age-predicted maximum heart rate - Cardiac catheterisation is the gold standard, and angiography counts the affected vessels and grades the narrowing IF NOT THIS - what else fits (11) - Acute pericarditis, myocarditis or a pericardial effusion - Prinzmetal angina from coronary spasm - Chest infection: acute bronchitis or pneumonia; also pleurisy or fluid in the pleural space - Aortic dissection - Reflux disease, peptic ulcer, or an oesophageal motility problem - Costochondritis - Coronary artery vasospasm or a dilated cardiomyopathy - Familial hypercholesterolaemia - Giant cell arteritis - High blood pressure and hypertensive heart disease - Kawasaki disease Source StatPearls "Coronary Artery Disease" - disease-level clinical article Status traced to the source above 1. ATORVASTATIN [1st line] Adult 80 mg once daily (secondary-prevention statin dose for established atherosclerotic/ischaemic heart disease). - Long-term / indefinite. Peds Not applicable - chronic ischaemic heart disease is an adult condition; paediatric statin dosing (from age 10, for familial hypercholesterolaemia only) is specialist-set and is not reproduced here. Source Egyptian National Drug Formulary - cardiovascular.pdf, Atorvastatin monograph (chapter PDF p207) Why High-intensity statin therapy is a core secondary-prevention drug for anyone with established coronary artery disease, reducing future cardiovascular events regardless of baseline cholesterol. Caution New or worsening chest pain, breathlessness at rest, syncope, symptoms suggesting unstable angina or heart failure. Check liver function and creatine kinase before starting and if muscle symptoms develop. Avoid in active liver disease and in pregnancy/breastfeeding. Watch for myopathy, especially with interacting drugs (e.g. clarithromycin, fibrates). Counsel on the need for long-term adherence even though the patient is asymptomatic. Egypt PREVENVAST 10 MG 10 TAB. CID 6.50 EGP (0.65/unit) ANTICHOL 10 MG 10 F.C. TAB. JEDCO INT. CO... 8.50 EGP (0.85/unit) LIPOVAST 10MG 7 F.C.TAB. MISR 9.25 EGP (1.32/unit) LIRIMAR 80 MG 10 CAPS. RIVA PHARMA S... 29.00 EGP (2.90/unit) LIPINORM 10 MG 7 F.C.TAB. MUP 28.00 EGP (4.00/unit) ATOR 40 MG 10 F.C.TABS. EIPICO 106.00 EGP (10.60/unit) HIPOLIXAVAST 10 MG 30 CHEW. TABS. EGPI 114.00 EGP HIPOLIXAVAST 20 MG 30 CHEW. TABS. EGPI 127.50 EGP 2. ISOSORBIDE-5-MONONITRATE [2nd line] Adult Immediate-release 20 mg twice daily, the two doses given about 7 hours apart (e.g. 8 AM and 3 PM) to reduce nitrate-tolerance development. - Ongoing, as directed (chronic anti- anginal prophylaxis). Peds Not used in children; angina from coronary artery disease is an adult condition and paediatric dosing is not established. Source Egyptian National Drug Formulary - cardiovascular.pdf, Isosorbide mononitrate monograph (chapter PDF p71) Why Isosorbide mononitrate is a standard oral anti-anginal used to prevent angina symptoms in chronic ischaemic heart disease. Caution Contraindicated with PDE5 inhibitors (sildenafil, tadalafil) - risk of severe hypotension. Causes headache and postural hypotension, especially at initiation. Give the two daily doses asymmetrically (not evenly 12 hours apart) to preserve a nitrate-free interval and avoid tolerance. Does not have a fast enough onset to abort an acute anginal attack - use sublingual GTN for acute episodes. Egypt ISOSORBIDE 20MG 10 TAB. SIGMA 3.00 EGP (0.30/unit) ISOSORBIDE 40MG 10 TAB. SIGMA 4.50 EGP (0.45/unit) CARDIOGUARD M 20MG SR 10CAPS. AMOUN 6.00 EGP (0.60/unit) CARDIOGUARD M 40 MG SR 10 CAPS. AMOUN 10.00 EGP (1.00/unit) ANGIOFOX (EFFOX) 40 MG 20 TABS. MINA PHARM 28.00 EGP (1.40/unit) MONOMAK 40MG 20 TAB. OCTOBER PHARMA 43.00 EGP (2.15/unit) MONOMAK DEPOT 100MG 10 F.C.TAB. OCTOBER PHARMA 48.00 EGP (4.80/unit) ANGIOFOX (EFFOX) 50MG LONG 20 CAPS. MINA PHARM 132.00 EGP (6.60/unit) 3. CLOPIDOGREL [3rd line] Adult 75 mg once daily (maintenance antiplatelet dose for secondary prevention after myocardial infarction, ischaemic stroke, or atherosclerotic disease). - Long-term / indefinite, as directed. Peds Not used in children; ischaemic heart disease is an adult condition. Source Egyptian National Drug Formulary - cardiovascular.pdf, Clopidogrel monograph (chapter PDF p119) Why Clopidogrel provides ongoing antiplatelet secondary prevention in confirmed atherosclerotic coronary disease. Caution Increases bleeding risk - caution with other antiplatelets/anticoagulants and before surgery. Avoid in active pathological bleeding (e.g. peptic ulcer, intracranial haemorrhage). Effectiveness is reduced by strong CYP2C19 inhibitors such as omeprazole - use pantoprazole instead if a PPI is needed. If combined with aspirin, bleeding risk is higher - confirm indication and planned duration of dual therapy. Egypt BLOTAGRIL 75MG 30 F.C. TABS. MEDIZEN PHARM... 33.00 EGP (1.10/unit) ITOLAVIX 75 MG 30 F.C. TABS. SIGMA > INTER... 54.00 EGP (1.80/unit) BORGAVIX 75MG 30 F.C. TABLETS BORG 66.00 EGP (2.20/unit) SIGAGREL 75MG 10 F.C. TAB. SIGMA 30.00 EGP (3.00/unit) CLOPACIRC 75 MG 30 F.C.TABS. COPAD PHARMA 117.00 EGP (3.90/unit) IDIAVIX 75MG 10 F.C.TAB. INTERNATIONAL... 48.00 EGP (4.80/unit) PLAVIX 75 MG 28 F.C.TABS. SANOFI WINTHR... 311.00 EGP (11.11/unit) PLAVIX 300 MG 30 F.C.TABS. SANOFI WINTHR... 704.00 EGP (23.47/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)