What are the specific drug names and dosages for the diagnosis and management of angina?

Pharmacological Management of Angina: Specific Drugs and Dosages

For the management of angina, beta-blockers and/or calcium channel blockers should be used as first-line treatment, with short-acting nitrates for immediate symptom relief, followed by other antianginal medications as needed based on symptom control. 1, 2

Immediate Symptom Relief

• Short-acting nitrates:
  • Sublingual nitroglycerin 0.3-0.6 mg as needed for acute angina episodes
  • Buccal nitroglycerin if sublingual preparations are ineffective
  • Should be used before engaging in activities that may trigger angina 1

First-Line Antianginal Therapy

Beta-blockers

• Metoprolol: 25-100 mg twice daily
• Atenolol: 25-100 mg once daily
• Bisoprolol: 2.5-10 mg once daily
• Carvedilol: 3.125-25 mg twice daily

Beta-blockers should not be abruptly discontinued; taper over 4 weeks if discontinuation is necessary 1

Calcium Channel Blockers (CCBs)

• Dihydropyridines:
  • Amlodipine: 5-10 mg once daily 3
  • Nifedipine XL: 30-90 mg once daily
• Non-dihydropyridines:
  • Diltiazem CD: 120-360 mg once daily
  • Verapamil SR: 120-480 mg daily (divided doses)

Amlodipine 10 mg has been shown to increase exercise time by 12.8% (63 sec) in chronic stable angina 3

Second-Line Antianginal Therapy

Long-acting nitrates

• Isosorbide dinitrate: 10-40 mg three times daily (with nitrate-free interval)
• Isosorbide mononitrate: 30-120 mg once daily (extended-release)
• Transdermal nitroglycerin patches: 0.2-0.8 mg/hour (apply for 12-14 hours daily with 10-12 hour nitrate-free interval)

All nitrates should be used with a nitrate-free interval (10-12 hours) to prevent tolerance 1

Other Antianginal Agents

• Ranolazine: 500-1000 mg twice daily 4
  • Effective as add-on therapy with amlodipine 10 mg daily
  • Significantly decreases angina attack frequency and nitroglycerin use

Preventive Therapy (Disease Modification)

Antiplatelet Therapy

• Aspirin: 75-100 mg daily (lifelong) 1
• Clopidogrel: 75 mg daily (alternative for aspirin-intolerant patients) 1

Lipid-Lowering Therapy

• Statins: All patients with chronic coronary syndrome should receive statins 1, 2
  • Atorvastatin: 20-80 mg daily
  • Rosuvastatin: 10-40 mg daily
• Ezetimibe: 10 mg daily (add if LDL goals not achieved with maximum tolerated statin) 1
• PCSK9 inhibitors: Consider for very high-risk patients not achieving goals on maximum statin plus ezetimibe 1

Additional Preventive Medications

• ACE inhibitors/ARBs: Recommended for patients with heart failure, LV dysfunction, hypertension, or diabetes 1, 2
• Proton pump inhibitors: Recommended for patients on antiplatelet therapy with high bleeding risk 1

Treatment Algorithm

1. Initial management:

   • Start with short-acting nitrates for immediate relief
   • Begin either beta-blocker OR calcium channel blocker as first-line therapy
   • Add aspirin 75-100 mg daily and statin therapy

2. If symptoms persist on monotherapy:

   • Add second agent (combine beta-blocker with dihydropyridine CCB)
   • Avoid combining beta-blockers with non-dihydropyridine CCBs due to risk of bradycardia and heart block

3. If symptoms persist on dual therapy:

   • Add long-acting nitrates with nitrate-free interval
   • Consider ranolazine 500-1000 mg twice daily as add-on therapy

4. For refractory symptoms:

   • Consider revascularization (PCI or CABG)
   • Evaluate for high-risk features requiring invasive management

Important Considerations and Contraindications

• Beta-blockers are contraindicated in severe bradycardia, high-degree AV block, and severe bronchospastic disease
• Non-dihydropyridine CCBs (verapamil, diltiazem) should not be combined with beta-blockers in patients with conduction disorders
• Nitrates are contraindicated with phosphodiesterase inhibitors (sildenafil, tadalafil) and in hypertrophic obstructive cardiomyopathy 1
• Ivabradine is not recommended as add-on therapy in patients with CCS, LVEF >40%, and no clinical heart failure 1
• Combination of ivabradine with non-dihydropyridine CCBs or other strong CYP3A4 inhibitors is not recommended 1

Monitoring and Follow-up

• Review treatment response after 2-4 weeks of initiating or changing therapy 1
• Assess symptom frequency, severity, medication adherence, and side effects
• Titrate medications to optimal doses before adding additional agents
• Monitor for drug interactions, especially when multiple antianginal medications are used

By following this evidence-based approach to angina management with specific drug choices and dosages, mortality and morbidity can be reduced while improving patients' quality of life and symptom control.