What medications are used to treat angina?

From the Guidelines

Medications commonly used to treat angina include nitrates, beta-blockers, calcium channel blockers, and antiplatelet agents. According to the most recent expert consensus document, a 'diamond' approach to personalized treatment of angina, first-choice medications for symptomatic angina are β-blockers, calcium-channel blockers, and short-acting nitrates 1. Nitrates like nitroglycerin (0.3-0.6 mg sublingually as needed for acute attacks, or long-acting forms like isosorbide mononitrate 30-60 mg daily) work by dilating blood vessels to improve blood flow to the heart. Beta-blockers such as metoprolol (25-100 mg twice daily) or atenolol (25-100 mg daily) reduce heart rate and blood pressure, decreasing the heart's oxygen demand. Calcium channel blockers like amlodipine (5-10 mg daily) or diltiazem (120-360 mg daily) relax blood vessels and reduce the heart's workload.

Key Medications for Angina Treatment

• Nitrates: nitroglycerin (0.3-0.6 mg sublingually as needed) or isosorbide mononitrate (30-60 mg daily)
• Beta-blockers: metoprolol (25-100 mg twice daily) or atenolol (25-100 mg daily)
• Calcium channel blockers: amlodipine (5-10 mg daily) or diltiazem (120-360 mg daily)

Additional Considerations

Antiplatelet medications such as aspirin (81-325 mg daily) help prevent blood clots. For high-risk patients, ranolazine (500-1000 mg twice daily) may be added when other medications aren't fully effective. Treatment typically begins with one medication and others are added as needed based on symptom control. Lifestyle modifications including regular exercise, smoking cessation, and stress management are also essential components of angina management. These medications work together to balance oxygen supply and demand in the heart muscle, reducing the frequency and severity of angina attacks and improving quality of life. The American College of Physicians also recommends the use of aspirin, β-blockers, and statins to prevent MI or death in patients with symptomatic chronic stable angina 1.

From the FDA Drug Label

14 CLINICAL STUDIES 14. 1 Chronic Stable Angina

CARISA (Combination Assessment of Ranolazine In Stable Angina) was a study in 823 chronic angina patients randomized to receive 12 weeks of treatment with twice-daily RANEXA 750 mg, 1000 mg, or placebo, who also continued on daily doses of atenolol 50 mg, amlodipine 5 mg, or diltiazem CD 180 mg.

1 INDICATIONS & USAGE 1. 2 Coronary Artery Disease (CAD)

Chronic Stable Angina Amlodipine besylate tablets is indicated for the symptomatic treatment of chronic stable angina.

The medications used to treat angina include:

• Ranolazine (2)
• Amlodipine (3) These medications are used for the symptomatic treatment of chronic stable angina.

From the Research

Medications for Angina

The following medications are used to treat angina:

• Nitrates, which remain the initial treatment for relief or prevention of angina in patients with coronary artery disease 4
• Beta blockers, such as atenolol, which are the first-line symptomatic treatment for stable angina 5
• Calcium channel blockers, such as verapamil and amlodipine, which are second-line alternatives for stable angina 5
• Ranolazine, which is authorized for symptomatic adjuvant treatment of angina in patients who are poorly controlled by a beta blocker and/or a calcium channel blocker 5
• Ivabradine, which is a channel inhibitor that has been shown to be equivalent to beta blockers and calcium antagonists in the treatment of angina 6
• Nicorandil and trimetazidine, which are second-line drugs indicated for patients who have contraindications to first-line agents, do not tolerate them, or remain symptomatic 6

Combination Therapy

Combination therapy with nitrates and other antianginal drugs, such as beta blockers and calcium antagonists, may be used in severe cases of angina 7

• The combination of nitrates and beta blockers is a rational approach, as the pharmacological actions of the two drugs produce complementary hemodynamic effects 7
• The combination of nitrates and calcium antagonists may be more or less attractive, depending on the profile of action of the particular calcium antagonist used 7
• Triple therapy with nitrates, beta blockers, and calcium antagonists may be used in some patients, but it is based more on clinical experience than on the effect documented in properly designed clinical studies 7

Treatment Objectives

The objectives in treating angina are relief of pain and prevention of disease progression through risk reduction 8

• Mechanisms, indications, clinical forms, doses, and side effects of traditional antianginal agents, such as nitrates, beta blockers, and calcium channel blockers, are reviewed 8
• Newer alternatives, such as ranolazine, may be used in patients who are poorly controlled by traditional antianginal agents 8