Persistent angina after MI and PCI with diabetes — case discussion

Presentation

Practice case (not a real patient). A 69-year-old man in a regional Australian town had PCI for an anterior MI 18 months ago and has completed DAPT. He now takes aspirin, atorvastatin at the highest dose he tolerates, ramipril and bisoprolol.^[1] He has angina when walking briskly uphill, despite bisoprolol, with a resting heart rate of 57 beats per minute and blood pressure 142/86 mmHg.^[1] His LVEF is 60%, without clinical heart failure. He has no indication for oral anticoagulation. He has type 2 diabetes on metformin with HbA1c 7.2%, and his LDL-C is 1.8 mmol/L. He stopped smoking a year ago and has not been vaccinated this winter.^[1]

Step 1 — Angina

Discussion:

• His heart rate is already at the ESC 2024 resting aim of 55–60 beats per minute for antianginal beta-blocker use.^[1]
• ESC 2024: if angina is not controlled by a beta-blocker alone, a beta-blocker plus a dihydropyridine CCB should be considered, unless contraindicated (Class IIa, Level B).^[1]
• ESC 2024: ivabradine is not recommended as add-on therapy with LVEF >40% and no clinical heart failure (Class III, Level B); AHA/ACC 2023 calls ivabradine added to standard therapy with normal LV function potentially harmful (COR 3: Harm).^[1][2]
• If symptoms persist, ESC 2024 says long-acting nitrates or ranolazine should be considered as add-on therapy (Class IIa, Level B); AHA/ACC 2023 recommends ranolazine when symptoms persist despite beta blockers, CCB or long-acting nitrates (COR 1, LOE B-R).^[1][2]
• He should also have a short-acting nitrate for immediate relief (ESC 2024, Class I, Level B).^[1]

Step 2 — Event prevention

Discussion:

• With no clear indication for oral anticoagulation and a prior MI or remote PCI, aspirin 75–100 mg daily is recommended lifelong after an initial period of DAPT (ESC 2024, Class I, Level A); NHFA/CSANZ 2025 says to prescribe a long-term P2Y12 inhibitor over aspirin after a completed course of DAPT following an ACS (strong recommendation, moderate certainty).^[1][6]
• His LDL-C of 1.8 mmol/L is above the ESC 2024 goal of <1.4 mmol/L with a ≥50% reduction from baseline (Class I, Level A), so ezetimibe is recommended with the maximum tolerated statin (Class I, Level B); NHFA/CSANZ 2025 gives the same initial LDL-C target after ACS (consensus).^[1][6]
• With type 2 diabetes, an SGLT2 inhibitor or a GLP-1 receptor agonist with proven cardiovascular benefit is recommended to reduce events, independent of HbA1c (ESC 2024, each Class I, Level A).^[1]
• His ramipril fits the ESC 2024 row for ACE inhibitors with comorbidities such as diabetes (Class I, Level A).^[1]
• With atherosclerotic CAD, low-dose colchicine 0.5 mg daily should be considered (ESC 2024, Class IIa, Level A).^[1]

Step 3 — Lifestyle, rehabilitation and vaccination

Discussion:

• Cardiac rehabilitation is recommended after ACS or with CCS, with or without PCI or CABG (ESC 2026, Class I, Level A); ESC 2026 says telerehabilitation or hybrid telerehabilitation should be considered as an alternative to centre-based programmes (Class IIa, Level B1).^[3]
• Aerobic activity of at least 150–300 min per week of moderate intensity, or 75–150 min of vigorous intensity, is recommended (ESC 2024, Class I, Level B).^[1]
• Annual influenza vaccination is recommended (AHA/ACC 2023, COR 1, LOE A); NHFA/CSANZ 2025 lists influenza, pneumococcal, respiratory syncytial virus (aged 60 years or older) and COVID-19 vaccines for people with ACS.^[2][6]

Step 4 — Follow-up and when to refer

Discussion:

• ESC 2024 recommends periodic visits (e.g. annual) regardless of symptoms (Class I, Level C), with an annual review of symptoms, medicines, examination, ECG and blood tests.^[1]
• If angina persists despite guideline-directed medical treatment, ESC 2024 recommends revascularisation of functionally significant obstructive CAD to improve symptoms (Class I, Level A).^[1]
• With symptoms refractory to medical treatment, ESC 2024 recommends invasive coronary angiography (with FFR/iFR when necessary) for risk stratification and possible revascularisation (Class I, Level C).^[1]