What is the initial treatment for stable angina?

Initial Treatment for Stable Angina

The initial treatment for stable angina should include short-acting sublingual nitroglycerin for acute symptom relief, along with a beta-blocker as first-line therapy for regular symptom control. 1

Pharmacological Management Algorithm

First-Line Therapy

1. Immediate symptom relief:

   • Short-acting sublingual or buccal nitroglycerin for acute episodes and situational prophylaxis 1
   • Instruct patients on proper use: sit during first few doses to avoid hypotension, use before activities that might trigger angina 1

2. Regular anti-anginal therapy:

   • Beta-blockers (first-line) - titrate to full dose and consider 24-hour protection against ischemia 1
   • Examples: metoprolol, atenolol, bisoprolol
   • Monitor for side effects: fatigue, bradycardia, bronchospasm

Second-Line Therapy (if beta-blockers ineffective or contraindicated)

• Calcium channel blockers (particularly long-acting formulations) 1
• Long-acting nitrates (with a nitrate-free interval to prevent tolerance) 1, 2
• Nicorandil (where available) 1

Third-Line Therapy

• If monotherapy is insufficient, add a dihydropyridine calcium channel blocker to beta-blocker 1
• If combination therapy fails, consider referral for revascularization rather than adding a third drug 1

Cardioprotective Medications

All patients with stable angina should also receive:

1. Antiplatelet therapy:

   • Aspirin 75-150 mg daily (unless contraindicated) 1
   • Clopidogrel 75 mg daily if aspirin is contraindicated 1

2. Lipid-lowering therapy:

   • Statin therapy for all patients with coronary artery disease 1
   • Target appropriate LDL cholesterol levels based on risk

3. ACE inhibitors:

   • Recommended for patients with concurrent hypertension, diabetes, heart failure, or prior MI 1

Special Considerations

Vasospastic Angina

• Calcium channel blockers are first-line therapy (high doses may be required)
• Nitrates can be added for additional symptom control 1

Important Caveats

1. Nitrate tolerance: Ensure a daily nitrate-free interval (10-14 hours) when using long-acting nitrates 1, 3, 2
2. Beta-blocker contraindications: Asthma, symptomatic peripheral vascular disease, and first-degree heart block 1
3. Calcium channel blockers: Avoid short-acting dihydropyridines when not combined with beta-blockers 1
4. Medication adherence: Poor adherence is a common cause of treatment failure 1

Risk Factor Modification

• Smoking cessation
• Regular physical activity within patient limitations
• Weight reduction if overweight
• Blood pressure control
• Diabetes management
• Stress management 1

If symptoms persist despite optimal medical therapy with two drugs at maximum tolerated doses, patients should be referred for consideration of revascularization procedures rather than adding a third medication 1.