What is the drug of choice for chronic stable angina?

Beta-Blockers Are the First-Line Drug of Choice for Chronic Stable Angina

Beta-blockers should be used as first-line therapy for chronic management of stable angina due to their effectiveness in reducing symptoms and their potential benefits on morbidity and mortality 1, 2.

Evidence-Based Treatment Algorithm

First-Line Therapy:

• Beta-blockers (e.g., atenolol, metoprolol)
  • Reduce heart rate and myocardial contractility, decreasing oxygen demand
  • Particularly beneficial in patients with prior myocardial infarction, hypertension, or supraventricular tachyarrhythmias 2, 3
  • Should be titrated to optimal dosage before adding other agents 2

Alternative First-Line Options (when beta-blockers are contraindicated):

• Calcium channel blockers (e.g., amlodipine, diltiazem)
  • Preferred when beta-blockers are contraindicated or not tolerated 1, 4
  • Dihydropyridines (amlodipine) can be used with beta-blockers if needed 4
  • Non-dihydropyridines (verapamil, diltiazem) should not be combined with beta-blockers due to risk of heart block 2

Second-Line Therapy (if symptoms persist):

• Long-acting nitrates
  • Require a daily "nitrate-free" interval of 10-12 hours to prevent tolerance 1
  • Can be added to beta-blockers or calcium channel blockers 2

Third-Line Options:

• Ranolazine - Effective as add-on therapy with minimal effects on heart rate and blood pressure 5, 6
• Ivabradine - Useful when heart rate control is needed without blood pressure effects 2, 6
• Nicorandil or Trimetazidine - Alternative options in specific clinical scenarios 2, 6

Special Clinical Scenarios

Comorbid Conditions Affecting Drug Choice:

1. Peripheral artery disease:

   • Beta-blockers should be used with caution or avoided
   • Prefer ranolazine, ivabradine, or trimetazidine 2

2. AV conduction defects:

   • Avoid beta-blockers and non-dihydropyridine calcium channel blockers
   • Consider nitrates, ranolazine, or other antianginals 2

3. Vasospastic angina:

   • Calcium channel blockers are first-line
   • Beta-blockers are contraindicated (may worsen spasm) 2

4. Microvascular angina:

   • Beta-blockers with a RAS blocker and statin 3

5. Post-MI patients:

   • Beta-blockers strongly recommended 2

Comprehensive Management

Essential Adjunctive Therapies:

• Aspirin (75-150 mg daily) for all patients without contraindications 2, 1
• Statins to target LDL-C <70 mg/dL 1
• ACE inhibitors for patients with hypertension, LV dysfunction, or diabetes 2, 1

Monitoring and Follow-up:

• Evaluate every 4-6 months during the first year, then annually if stable 2, 1
• Assess symptom frequency, medication adherence, and side effects at each visit 2

Common Pitfalls to Avoid

1. Suboptimal dosing - Many patients receive inadequate doses of antianginal medications 7
2. Failure to add second agent when monotherapy is insufficient 7
3. Inappropriate combinations - Combining beta-blockers with non-dihydropyridine calcium channel blockers can cause excessive bradycardia 2, 8
4. Neglecting nitrate-free intervals - Continuous nitrate therapy leads to tolerance 1
5. Overlooking aspirin therapy - Essential for all patients with stable coronary disease 2

Despite some studies showing equivalence between certain antianginal drugs 9, beta-blockers remain the preferred first-line therapy based on their potential mortality benefits in post-MI patients and effectiveness in symptom control, as recommended by major cardiology societies 2, 1.