From the Guidelines
Treatment for microvascular angina should focus on symptom relief and improving quality of life, with ranolazine being a potential option to reduce mechanical compression of coronary microcirculation, as suggested by a 2018 expert consensus document 1. The approach to treating microvascular angina is extremely challenging and necessarily empirical, with no conclusive evidence supporting a specific class of drugs. However, some medications have shown promise in reducing symptoms.
- Slowing the heart rate with β-blockers, diltiazem, verapamil, or ivabradine can be considered due to increased diastolic time and coronary perfusion.
- Co-administration of ranolazine or trimetazidine might also be useful in improving coronary self-regulation and reducing anginal symptoms.
- In patients with enhanced pain perception, adenosine antagonists and drugs effective in chronic pain syndromes, such as imipramine, are other therapeutic options. It is essential to individualize treatment based on symptom severity, comorbidities, and medication tolerability, with regular follow-up to assess effectiveness and adjust therapy as needed, as noted in the 2018 expert consensus document 1.
- The effects of ivabradine were superior to those of bisoprolol, despite similar degrees of heart-rate reduction, making it a potential option for patients with microvascular angina.
- A small trial with ranolazine suggested improvement of anginal symptoms in women with microvascular angina, although subsequent studies have yielded mixed results, highlighting the need for personalized treatment approaches 1.
From the Research
Treatment Options for Microvascular Angina
The treatment of microvascular angina (MVA) is primarily based on standard anti-ischemic drugs, including:
- Beta-blockers: reduce heart rate and myocardial contractility, thus reducing myocardial oxygen consumption 2, 3, 4
- Calcium antagonists: have been shown to be beneficial in controlling symptoms in some patients 2, 5, 3
- Nitrates: although not effective in the treatment of MVA, unlike vasospastic angina 3
Additional Therapies
In cases where standard anti-ischemic drugs are insufficient, several additional drugs have been proposed, including:
- Ranolazine: has potential anti-ischemic effects 2
- Ivabradine: has potential anti-ischemic effects 2
- Angiotensin-converting enzyme (ACE) inhibitors: have been shown to be beneficial in patients with MVA 2, 3, 6
- Xanthine derivatives: have been proposed as an alternative form of treatment 2, 5
- Nicorandil: has potential anti-ischemic effects 2
- Statins: have been shown to be beneficial in patients with MVA 2, 3, 6
- Alpha-blockers: have been proposed as an alternative form of treatment 2, 5
- Estrogens: have been proposed as an alternative form of treatment in perimenopausal women 2, 5, 3
Alternative Therapies for Refractory MVA
In patients with refractory MVA, some further alternative therapies have shown favorable results, including: