From the Guidelines
The initial workup for stable angina should include a thorough history and physical examination, 12-lead ECG, cardiac biomarkers, fasting lipid profile, blood glucose, complete blood count, and renal function tests, as recommended by the American College of Physicians 1.
Initial Workup
The initial workup for stable angina should prioritize the following:
- A thorough history and physical examination to identify potential risk factors and symptoms
- 12-lead ECG to assess for any signs of ischemia or previous myocardial infarction
- Cardiac biomarkers, such as troponin, to rule out acute myocardial infarction
- Fasting lipid profile, blood glucose, complete blood count, and renal function tests to evaluate for any underlying conditions that may be contributing to the angina
Imaging Studies
Imaging studies should include:
- A resting echocardiogram to assess cardiac structure and function
- Stress testing (exercise or pharmacological) with imaging to evaluate for inducible ischemia, as recommended by the European Society of Cardiology 1
Management
Management of stable angina should begin with lifestyle modifications, including:
- Smoking cessation
- Regular physical activity
- Weight management
- A heart-healthy diet First-line pharmacotherapy should include:
- Aspirin (75-100 mg daily) for antiplatelet therapy
- A moderate-intensity statin, such as atorvastatin 20-40 mg daily, for lipid management
- Anti-anginal medications, such as beta-blockers (e.g., metoprolol 25-100 mg twice daily) or calcium channel blockers (e.g., amlodipine 5-10 mg daily) Sublingual nitroglycerin (0.4 mg as needed) should be prescribed for acute angina episodes, and long-acting nitrates, such as isosorbide mononitrate (30-60 mg daily), should be added if symptoms persist, while ensuring a nitrate-free period to prevent tolerance.
Follow-up
Follow-up should include regular evaluations every 4 to 6 months during the first year of therapy, and annual evaluations thereafter, as recommended by the American College of Physicians 1. Patients should be educated about angina symptoms, when to seek emergency care, and the importance of medication adherence. Referral for coronary angiography should be considered for patients with high-risk features or inadequate symptom control despite optimal medical therapy.
From the FDA Drug Label
In the CARISA (Combination Assessment of Ranolazine In Stable Angina) trial, 823 chronic angina patients were randomized to receive 12 weeks of treatment with twice-daily Ranolazine Extended-Release Tablets 750 mg, 1000 mg, or placebo, who also continued on daily doses of atenolol 50 mg, amlodipine 5 mg, or diltiazem CD 180 mg. Sublingual nitrates were used in this study as needed.
The initial workup and management for a patient with stable angina is not directly addressed in the provided drug labels.
- Key points to consider in the management of stable angina include:
- The use of sublingual nitrates as needed to treat angina episodes.
- The potential use of antianginal agents such as ranolazine, amlodipine, or diltiazem.
- The importance of evaluating the patient's response to treatment and adjusting the management plan as needed. However, the FDA drug label does not provide a comprehensive approach to the initial workup and management of stable angina. 2 2
From the Research
Initial Workup for Stable Angina
The initial workup for a patient with stable angina begins with:
- Careful history taking and evaluation of various risk factors 3
- Physical examination 3, 4
- A resting electrocardiogram (ECG) 3, 4, 5
- Laboratory tests for diabetes and hyperlipidemia 4
Risk Stratification
Risk stratification is valuable for determining the best course of treatment. This can be achieved through:
- A noninvasive exercise stress test 3, 4, 5
- Stress imaging procedures, such as thallium scintigraphy or coronary computed tomographic angiography, for patients with abnormal resting ECG or equivocal stress test results 3, 6
- Cardiac catheterization for patients with chest discomfort and multiple risk factors, severe or progressive angina, or congestive heart failure 3, 4
Management of Stable Angina
The management of stable angina involves:
- Medical therapy with nitrates, beta-adrenergic blockers, and calcium channel blockers 3, 6, 7
- Revascularization with coronary artery bypass graft or percutaneous transluminal coronary angioplasty (PTCA) for patients with left main coronary artery disease, left ventricular dysfunction, or severe proximal three-vessel coronary artery disease 3, 6
- Optimization of lifestyle factors and preventive medications, such as lipid-lowering and antiplatelet agents, to reduce the risk of cardiovascular events and death 6
- Emphasis on improving angina symptoms and quality of life through antianginal medications and revascularization, if necessary 6
Diagnostic Tests
Diagnostic tests for stable angina include:
- Exercise electrocardiography 4
- Stress imaging procedures, such as exercise echocardiography or myocardial perfusion imaging 4
- Coronary computed tomographic angiography 6
- Cardiac catheterization 3, 4
Treatment Approach
The treatment approach for stable angina should be individualized, taking into account the patient's risk factors, symptoms, and quality of life. Shared decision-making with an informed patient is important for effective treatment 6.