What is the assessment and treatment plan for a patient with stable angina?

Assessment and Management of Stable Angina

The optimal management of stable angina requires a combination of antiplatelet therapy, statins, and beta-blockers as first-line antianginal medications, along with lifestyle modifications to reduce cardiovascular risk factors. 1

Assessment

Clinical Evaluation

• Evaluate angina symptoms using Canadian Cardiovascular Society (CCS) classification
• Assess frequency, severity, and triggers of anginal episodes
• Identify risk factors: diabetes, hypertension, smoking, obesity, dyslipidemia
• Determine if patient has decreased physical activity to avoid symptoms 2

Diagnostic Testing

• Exercise ECG testing is the preferred initial test for patients who can exercise and have a normal resting ECG 2
• Stress imaging (echocardiography or nuclear) is indicated when:
  • Exercise ECG is not possible or interpretable
  • Patient has pre-existing ECG abnormalities (LBBB, paced rhythm, >1mm ST depression at rest)
  • Initial exercise ECG yields equivocal or intermediate-risk results 2
• Coronary angiography is indicated for patients with:
  • Marked limitation of ordinary activity (CCS class III) despite maximal medical therapy
  • High-risk features on non-invasive testing 2

Treatment Plan

Pharmacological Therapy

Anti-ischemic Medications

1. First-line therapy: Beta-blockers

   • Optimize dose before adding another medication
   • Contraindicated in severe bradycardia and advanced AV block 1

2. Alternative first-line therapy: Calcium channel blockers

   • When beta-blockers are contraindicated or not tolerated 1, 3
   • Both dihydropyridines and non-dihydropyridines are effective 4

3. Second-line therapy: Long-acting nitrates

   • Require nitrate-free interval to prevent tolerance
   • May cause headaches as common side effect 1, 5

4. Additional options for refractory symptoms:

   • Ranolazine - shown to increase exercise duration and reduce angina frequency 6
   • Consider combination therapy when monotherapy is insufficient 5

Preventive Medications

1. Antiplatelet therapy:

   • Aspirin 75-325 mg daily for all patients without contraindications 1
   • Clopidogrel as alternative in aspirin-intolerant patients 1

2. Lipid-lowering therapy:

   • Statins for all patients with stable angina 1
   • Target LDL cholesterol according to current guidelines

3. ACE inhibitors:

   • Indicated for patients with co-existing ventricular dysfunction, hypertension, or diabetes 2

Lifestyle Modifications

• Smoking cessation with tailored strategies
• Weight control to achieve normal BMI
• Regular physical exercise (consider cardiac rehabilitation) 7
• Strict diabetic control
• Blood pressure control according to current guidelines 1

Revascularization

Consider revascularization when:

• Symptoms are not adequately controlled with optimal medical treatment
• Evidence of severe ischemia on non-invasive tests
• High-risk coronary anatomy (left main, proximal LAD, or three-vessel disease) 1, 4

Follow-up

• Regular follow-up every 4-12 months for stable patients 2
• Reassess for:
  • Changes in symptom frequency or severity
  • Decreased physical activity due to symptoms
  • Medication tolerance and adherence
  • Success in risk factor modification 2

Repeat Testing Recommendations

• Repeat stress testing only if significant change in clinical status
• Avoid routine repeat testing in stable patients with low risk (<1% annual mortality) 2
• Consider repeat echocardiography when:
  • Medications affecting cardiac conduction are changed
  • Anginal pattern has changed
  • Symptoms suggest dysrhythmia or conduction abnormality 2

Common Pitfalls to Avoid

• Failing to optimize monotherapy before adding additional medications
• Using continuous nitrate therapy without a nitrate-free interval (leads to tolerance)
• Triple therapy may not be more effective than dual therapy and increases side effects 5
• Overreliance on revascularization for symptom control without adequate trial of medical therapy
• Neglecting lifestyle modifications and risk factor management