What medications are recommended for managing angina?

Medication Management for Angina

First-line treatment for angina should include short-acting nitroglycerin for acute symptom relief, a beta-blocker as the foundation of regular therapy, and aspirin for cardiovascular protection. 1

Core Medication Strategy

Immediate Symptom Relief

• Short-acting nitroglycerin (sublingual or spray): Provide for all patients for acute symptom relief and situational prophylaxis
  • Use 2-3 minutes before activities that may trigger angina
  • Instruct patients that if pain persists after 3 doses taken 5 minutes apart, they should seek emergency care 1

First-Line Regular Therapy

1. Beta-blockers (start with these)

   • Target doses: bisoprolol 10 mg daily, metoprolol CR 200 mg daily, or atenolol 100 mg daily (or 50 mg twice daily)
   • Optimize dose before adding another agent
   • Provides 24-hour protection against ischemia
   • Caution: Do not stop suddenly; taper over 4 weeks 1

2. Aspirin 75-150 mg daily

   • Essential for all patients without specific contraindications
   • If aspirin contraindicated: clopidogrel 75 mg daily 1

Second-Line/Add-on Therapy

If symptoms persist despite optimized beta-blocker:

1. Add calcium channel blocker (preferably long-acting dihydropyridine)

   • Can be combined with beta-blockers for enhanced effect
   • For patients who cannot tolerate beta-blockers, calcium channel blockers can be used as monotherapy 1

2. Long-acting nitrates (alternative to calcium channel blockers)

   • Must include a nitrate-free interval (10-14 hours) to avoid tolerance
   • For transdermal patches: remove at night and apply new patch in morning
   • Can be used in combination with beta-blockers 1, 2

Special Situations

Vasospastic Angina

• Calcium channel blockers are first-line (high doses may be needed)
  • Up to 480 mg/day verapamil, 260 mg/day diltiazem, or 120 mg/day nifedipine
• Long-acting nitrates in combination with calcium channel blockers
• Consider nicorandil for refractory cases 1

Refractory Angina

If symptoms persist despite optimal two-drug therapy:

• Consider ranolazine (500-1000 mg twice daily)
  • Can be used with beta-blockers, nitrates, and calcium channel blockers 3, 4
• Other options include nicorandil or ivabradine (if heart rate elevated) 1, 5
• Consider referral for revascularization evaluation 1

Mortality Reduction Medications

In addition to symptom control, add:

• Statin therapy for all patients with documented coronary disease
• ACE inhibitor for patients with hypertension, heart failure, LV dysfunction, prior MI, or diabetes 1

Medication Selection Algorithm

1. Start with short-acting nitroglycerin + aspirin + beta-blocker
2. If symptoms persist after beta-blocker dose optimization:
   • Add long-acting calcium channel blocker OR
   • Add long-acting nitrate (with nitrate-free interval)
3. If symptoms still persist:
   • Try alternative combination (substitute calcium channel blocker for nitrate or vice versa)
   • Consider adding ranolazine
4. If three-drug regimen fails:
   • Refer for revascularization consideration 1

Common Pitfalls to Avoid

• Using continuous 24-hour nitrate therapy (causes tolerance)
• Using short-acting dihydropyridine calcium channel blockers without beta-blockers
• Abrupt discontinuation of beta-blockers
• Using dipyridamole or chelation therapy (not recommended) 1, 2

Remember to monitor medication effectiveness by tracking frequency of angina attacks and nitroglycerin use. Optimize doses of one drug before adding another, and if a third drug is introduced without benefit, it should be discontinued 1.