From the Guidelines
Medical management is the primary approach for treating angina when revascularization is not an option, focusing on a combination of medications and lifestyle modifications to reduce myocardial oxygen demand and increase oxygen supply. The treatment should start with a beta-blocker, such as metoprolol 25-100 mg twice daily or carvedilol 3.125-25 mg twice daily, to reduce heart rate and blood pressure, as recommended by the European Society of Cardiology guidelines 1.
Medication Regimen
- Add a long-acting nitrate like isosorbide mononitrate (30-60 mg once daily) or isosorbide dinitrate (20-40 mg three times daily) to dilate coronary arteries and improve blood flow.
- For immediate relief of acute angina attacks, prescribe sublingual nitroglycerin (0.4 mg as needed, may repeat every 5 minutes up to 3 doses).
- Calcium channel blockers such as amlodipine (5-10 mg daily) can be added if beta-blockers are contraindicated or for additional symptom control.
- Antiplatelet therapy with aspirin (75-100 mg daily) is essential to prevent thrombotic events, as suggested by the American College of Physicians guidelines 1.
- For refractory symptoms, ranolazine (500-1000 mg twice daily) may help by reducing calcium overload in cardiac cells without affecting heart rate or blood pressure.
Lifestyle Modifications
- Advise smoking cessation to reduce cardiovascular risk.
- Encourage regular moderate exercise within symptom limits to improve cardiovascular health.
- Recommend weight management and stress reduction techniques to decrease myocardial oxygen demand.
Follow-Up
Regular follow-up is crucial to monitor symptoms, adjust antianginal therapy, and address any new comorbid illnesses or changes in the patient's condition, as emphasized by the ACC/AHA guideline 1. The algorithm for medical management of stable angina provided by the European Society of Cardiology guidelines 1 can be a useful tool in guiding treatment decisions.
Key Considerations
- The choice of medication and lifestyle modifications should be tailored to the individual patient's needs and medical history.
- Regular assessment of the patient's response to treatment and adjustment of the treatment plan as needed is essential to optimize outcomes.
- Consideration of alternative therapies, such as spinal cord stimulation, enhanced external counterpulsation, and laser transmyocardial revascularization, may be necessary for patients who cannot be managed adequately by medical therapy and are not candidates for revascularization, as noted by the ACC/AHA writing committee 1.
From the FDA Drug Label
The effectiveness of 5 to 10 mg/day of amlodipine in exercise-induced angina has been evaluated in 8 placebo-controlled, double-blind clinical trials of up to 6 weeks duration involving 1038 patients (684 amlodipine, 354 placebo) with chronic stable angina In 5 of the 8 studies, significant increases in exercise time (bicycle or treadmill) were seen with the 10 mg dose. Amlodipine 10 mg also increased time to 1 mm ST segment deviation in several studies and decreased angina attack rate.
Treatment of Angina without Revascularization:
- Amlodipine can be used to treat angina in patients who are not able to undergo revascularization.
- The recommended dose is 5 to 10 mg/day, with significant increases in exercise time and decreases in angina attack rate seen with the 10 mg dose 2.
- Amlodipine may be used alone or in combination with other antianginal agents.
From the Research
Treatment Options for Angina
When revascularization is not possible, several treatment options can be considered for managing angina:
- Lifestyle changes, such as smoking cessation and regular exercise, can help alleviate symptoms 3
- Antianginal drugs, including beta-blockers and calcium channel blockers, can be used as first-line treatment 3
- Low-dose aspirin and statins can be used as disease-modifying agents 3
- Mononitrates, such as isosorbide 5-mononitrate, can be effective in preventing angina pectoris 4
- A combination of medical therapy, lifestyle interventions, and novel therapies can be considered for patients with refractory angina 5
Medical Therapy
Medical therapy for angina can include:
- Beta-blockers, such as metoprolol, which can prolong exercise time and reduce symptoms 6
- Calcium channel blockers, such as nisoldipine, which can also prolong exercise time and reduce symptoms 6
- Nitrates, such as isosorbide dinitrate, which can help relieve symptoms but may not be as effective as beta-blockers or calcium channel blockers 6
- A patient-centered approach, integrating revascularization, medical therapy, and lifestyle interventions, can be effective in managing stable angina 7
Novel Therapies
Novel therapies, such as those targeted towards specific pathogenic mechanisms, can be considered for patients with refractory angina or anginal equivalent symptoms despite maximal medical therapy 5, 7