MRCP2-0403
An 80-year-old woman presents to the cardiology outpatient department with angina. She experiences consistent chest tightness after walking around 200 metres on flat ground but denies any episodes of pain at rest. Her symptoms have been stable at the current level for at least six months. The patient has a history of heavy smoking but quit 15 years ago after suffering a non-ST elevation myocardial infarction. She was diagnosed with type 2 diabetes mellitus 10 years ago and has chronic kidney disease. Her GP previously attempted treatment with metoprolol and amlodipine, but both were stopped due to dizziness and hypotension.
The patient’s current medications include aspirin, simvastatin, ramipril, and gliclazide. She sometimes uses a nitrate spray to relieve episodes of angina but finds that it normally makes her very dizzy. Clinical examination was unremarkable except for a blood pressure of 98/65 mmHg. Recent investigations revealed moderately impaired left ventricular ejection fraction, mild myocardial ischemia in the left anterior descending territory, and abnormal blood test results.
What is the appropriate next line of therapy for this patient’s angina?