From the Guidelines
Angina upon exertion should be managed by stopping the activity causing symptoms and taking sublingual nitroglycerin (0.4 mg tablet) under the tongue, with long-term management including daily medications such as aspirin, a beta-blocker, and a statin, as well as lifestyle modifications like regular moderate exercise and a heart-healthy diet. This approach is based on the most recent guidelines for the management of chronic coronary syndromes, which emphasize the importance of prompt and appropriate management to control symptoms and improve prognosis 1.
Immediate Management
For immediate relief, it is recommended to stop the activity causing symptoms and take sublingual nitroglycerin (0.4 mg tablet) under the tongue, which can be repeated every 5 minutes for up to three doses if pain persists 1. If symptoms do not resolve after three doses, it is crucial to seek emergency medical attention.
Long-term Management
Long-term management typically includes daily medications such as:
- Aspirin (81-325 mg)
- A beta-blocker (like metoprolol 25-100 mg twice daily)
- A statin (such as atorvastatin 10-80 mg daily) Lifestyle modifications are also crucial, including:
- Regular moderate exercise within your tolerance level
- A heart-healthy diet low in saturated fats
- Smoking cessation
- Stress management
Importance of Accurate Diagnosis
It is essential to document coronary risk factors during history taking, as they may be modifiable and will be used for the pre-test likelihood estimation of obstructive CAD 1. The Canadian Cardiovascular Society classification is still widely used as a grading system for effort-induced angina to quantify the threshold at which symptoms occur with physical activities.
Considerations for Specific Patient Groups
Women have more frequent angina, independent of less extensive epicardial CAD, and less severe myocardial ischaemia than men 1. Angina at rest is not always indicative of severe, fixed obstructive CAD, as it may also occur in patients with transient epicardial or microvascular coronary vasospasm.
Overall Approach
The management of angina upon exertion should prioritize controlling symptoms, improving prognosis, and reducing the risk of progression to myocardial infarction or death, as outlined in the most recent guidelines for the management of chronic coronary syndromes 1.
From the FDA Drug Label
What is chronic angina? Chronic angina means pain or discomfort in the chest, jaw, shoulder, back, or arm that keeps coming back There are other possible signs and symptoms of angina including shortness of breath. Angina usually comes on when you are active or under stress. Tell your doctor if you still have symptoms of angina after starting Ranolazine Extended-Release Tablets
Ranolazine Extended-Release Tablets are used to treat chronic angina, which is characterized by pain or discomfort in the chest, jaw, shoulder, back, or arm that keeps coming back, often triggered by activity or stress. If symptoms of angina persist after starting Ranolazine Extended-Release Tablets, patients should inform their doctor 2.
From the Research
Angina Upon Exertion
- Angina pectoris is defined as substernal chest pain, pressure, or discomfort that is typically exacerbated by exertion and/or emotional stress, lasts greater than 30 to 60 seconds, and is relieved by rest and nitroglycerin 3.
- Approximately 10 million people in the United States have angina, with over 500,000 cases diagnosed per year, and angina itself is a predictor of major adverse cardiac events 3.
- Treatment for angina includes pharmacologic therapy such as β-blockers, nitrates, calcium channel blockers, and ranolazine, as well as revascularization in certain high-risk individuals 3.
Diagnosis and Management
- Diagnostic tests for stable angina have evolved, with coronary computed tomographic angiography being a first-line diagnostic test due to its higher sensitivity and comparable specificity compared with imaging-based stress testing 4.
- Novel therapies, such as proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and icosapent ethyl, have improved cardiovascular outcomes in patients with stable ischemic heart disease when added to usual care 4.
- Revascularization with percutaneous coronary intervention should be reserved for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy 4.
Treatment Options
- Nitroglycerin is a fast-acting vasodilator commonly used as a first-line agent for angina in the emergency department and to manage chest pain due to acute coronary syndromes 5.
- Treatment of microvascular coronary dysfunction (MCD) should be aimed at ischemia disease management to reduce the risk of adverse cardiac events, ameliorate symptoms to improve quality of life, and decrease morbidity from unnecessary and repeated cardiac catheterization 6.
- Current pharmacotherapy for MCD may include treatment of microvascular endothelial dysfunction (with statins, angiotensin-converting enzyme inhibitors, or low-dose aspirin), as well as treatment for angina and myocardial ischemia (with β-blockers, calcium channel blockers, nitrates, or ranolazine) 6.
Note: The study referenced by 7 is not relevant to the topic of angina upon exertion.