What is an alternative medication to a calcium channel blocker (CCB) for angina if the patient reports worsening pain with isosorbide mononitrate (Imdur) and amlodipine (Norvasc)?

From the Guidelines

Beta-blockers are the recommended alternative medication for a patient experiencing worsening angina symptoms with amlodipine and intolerance to Imdur (isosorbide mononitrate). According to the most recent and highest quality study 1, beta-blockers are the preferred first-line treatment for angina, especially in patients with left ventricular dysfunction and heart failure. They work by reducing heart rate, blood pressure, and myocardial contractility, which decreases oxygen demand in the heart muscle.

Alternative Medication Options

• Metoprolol tartrate 25-50 mg twice daily or metoprolol succinate (extended-release) 50-100 mg once daily are appropriate options.
• Other beta-blockers like atenolol (25-100 mg daily) or carvedilol (3.125-25 mg twice daily) could also be considered.
• If beta-blockers are contraindicated, ranolazine (500-1000 mg twice daily) could be considered as it works through a different mechanism by reducing calcium overload in cardiac cells without affecting heart rate or blood pressure significantly.

Important Considerations

• Start with a low dose and titrate upward as needed based on symptom control and heart rate response.
• Monitor for potential side effects including fatigue, bradycardia, bronchospasm, and hypotension.
• The European Society of Cardiology guidelines 1 also recommend beta-blockers as the preferred first-line treatment for angina, with alternatives such as ivabradine, nitrates, and nicorandil considered in specific cases.
• The choice of alternative medication should be based on the individual patient's comorbidities and contraindications, as outlined in the expert consensus document 1.

From the Research

Alternative Medications for Angina

If a patient reports worsening pain with Imdur and amlodipine, alternative medications can be considered.

• Ranolazine is a novel antianginal and anti-ischemic agent that can be used as monotherapy or added to other medications such as beta-blockers, nitrates, and calcium channel blockers 2.
• Nitrates, such as isosorbide dinitrate or isosorbide-5-mononitrate, can be effective in terminating acute attacks of angina pectoris and in the prophylaxis of symptomatic and asymptomatic myocardial ischemia, but may require intermittent therapy to prevent tolerance 3.
• Beta-blockers are effective in reducing mortality and adverse outcomes in patients with stable angina, and can be used as initial therapy, especially in patients with hypertension or a history of myocardial infarction 4, 5.
• Other medications, such as trimetazidine, ivabradine, nicorandil, and fasudil, may be available in other countries and can be considered as alternative treatments for angina 5.

Considerations for Choosing Alternative Medications

When choosing an alternative medication, several factors should be considered, including:

• The presence of concomitant diseases, such as hypertension or diabetes
• Underlying left ventricular function
• The patient's symptoms and quality of life
• The potential for adverse effects, such as headache or fatigue
• The need for intermittent therapy to prevent tolerance, as with nitrates 3, 4
• The availability of medications in different countries 5