How to manage stable angina?

From the Guidelines

Managing stable angina requires a comprehensive approach that prioritizes lifestyle modifications, medications, and sometimes procedures to reduce morbidity, mortality, and improve quality of life. The most recent and highest quality study, 1, published in 2018, suggests an individualized approach to angina treatment, considering the patient's comorbidities and the underlying mechanism of disease. Key aspects of management include:

• Addressing modifiable risk factors: quit smoking, maintain healthy weight, exercise regularly, follow a heart-healthy diet, and manage conditions like diabetes, hypertension, and high cholesterol.
• First-line medication therapy:
  • Aspirin (75-100mg daily) to prevent clotting,
  • A beta-blocker (such as metoprolol 25-100mg twice daily) to reduce heart rate and blood pressure,
  • A statin (like atorvastatin 20-80mg daily) to lower cholesterol.
• For symptom relief during angina attacks: sublingual nitroglycerin (0.4mg as needed) works quickly by dilating blood vessels.
• Long-acting nitrates (isosorbide mononitrate 30-60mg daily) may be added for ongoing prevention, but require a nitrate-free period of 10-14 hours daily to prevent tolerance.
• Calcium channel blockers (amlodipine 5-10mg daily) are alternatives for those who cannot tolerate beta-blockers. According to 1, for patients with symptomatic heart failure, a beta-blocker is recommended as the preferred first-line treatment to relieve angina, with alternatives including ivabradine, nitrates, and amlodipine for those who cannot tolerate beta-blockers. The goal is to reduce myocardial oxygen demand or increase oxygen supply, addressing the fundamental imbalance causing angina, and regular follow-up with healthcare providers is essential to monitor treatment effectiveness and adjust therapy as needed. In cases where symptoms persist despite optimal medical therapy, revascularization procedures like angioplasty with stenting or coronary artery bypass grafting may be necessary, as recommended by 1 and 1.

From the FDA Drug Label

In the CARISA (Combination Assessment of Ranolazine In Stable Angina) trial, statistically significant (p <0. 05) increases in modified Bruce treadmill exercise duration and time to angina were observed for each Ranolazine Extended-Release Tablets dose versus placebo, at both trough (12 hours after dosing) and peak (4 hours after dosing) plasma levels, with minimal effects on blood pressure and heart rate. The effects of Ranolazine Extended-Release Tablets on angina frequency and nitroglycerin use are shown in Table 2. Ranolazine Extended-Release Tablets has been evaluated in patients with chronic angina who remained symptomatic despite treatment with the maximum dose of an antianginal agent

To manage stable angina, the following approaches can be considered:

• Ranolazine Extended-Release Tablets can be used at a dose of 750 mg or 1000 mg twice daily, as it has been shown to increase exercise duration and time to angina, with minimal effects on blood pressure and heart rate 2.
• Concomitant treatment with other antianginal agents such as atenolol, amlodipine, or diltiazem can be used, as well as long-acting nitrates and sublingual nitrates as needed to treat angina episodes 2 2.
• Monitoring of angina frequency and nitroglycerin use is recommended to assess the effectiveness of the treatment.
• Dose adjustment may be necessary based on the patient's response to the treatment.

From the Research

Management of Stable Angina

Stable angina can be managed through a combination of lifestyle modifications, medications, and medical procedures. The goal of treatment is to improve quality of life, decrease cardiovascular events, and mortality.

Medications

• Beta blockers, nitrates, and calcium channel blockers are commonly used to manage stable angina 3, 4, 5, 6
• Aspirin should be used for all patients unless they are allergic or have other contraindications, and clopidogrel can be added to the therapy if necessary 3
• Angiotensin converting enzyme inhibitors should be used for patients with diabetes mellitus and/or left ventricular systolic dysfunction 3
• Ranolazine can be used for patients with limiting angina 3, 5

Medical Procedures

• Revascularization techniques, such as percutaneous coronary intervention, can be used to improve angina symptoms and quality of life, but should be reserved for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy 6
• Enhanced external counterpulsation can be considered for patients who have not responded to maximal drug therapy 3, 5

Lifestyle Modifications

• Patients should be evaluated for reversible causes of their angina, such as anemia, hyperthyroidism, sympathomimetic drugs, and hypertension 3
• Emphasis should be placed on optimizing lifestyle factors, such as diet and exercise, and preventive medications, such as lipid-lowering and antiplatelet agents, to reduce the risk for cardiovascular events and death 6

Diagnostic Tests

• Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina, allowing detection of nonobstructive atherosclerosis and improving risk assessment 6

Novel Therapies

• Novel therapies, such as proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and icosapent ethyl, can improve cardiovascular outcomes in patients with stable ischemic heart disease when added to usual care 6
• Sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists can also improve cardiovascular outcomes in patients with type 2 diabetes and stable ischemic heart disease 6