Personalized Medicine Selection Based on Patient Characteristics
The best medicine is one that is tailored to the specific patient's condition, comorbidities, and physiological parameters, as no single medication is universally superior for all patients. 1
General Principles of Medication Selection
- The selection of optimal medication therapy should follow a "diamond" approach that considers the patient's specific physiopathology, comorbidities, and risk factors 1
- No head-to-head comparisons between first-choice and second-choice treatments have demonstrated superiority of one group of drugs over another in terms of antianginal effects 1
- Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival 1
Medication Selection Algorithm Based on Patient Parameters
Heart Rate Considerations
- For patients with elevated heart rate (>70 bpm), heart-rate-lowering agents are preferred: 1
- β-blockers
- Non-dihydropyridine calcium-channel blockers (diltiazem and verapamil)
- Ivabradine (can be safely added to β-blockers when heart rate remains ≥70 bpm)
Blood Pressure Considerations
- For patients with hypotension (systolic <130 mmHg, diastolic <80 mmHg): 1
- Avoid calcium-channel blockers, nitrates, and β-blockers as they may impair coronary perfusion
- Prefer ivabradine (if associated with elevated heart rate), ranolazine, or trimetazidine
Left Ventricular Dysfunction and Heart Failure
- When chronic stable angina occurs with left ventricular systolic dysfunction: 1, 2
- Trimetazidine may be beneficial as add-on therapy
- Meta-analyses suggest trimetazidine improves metabolic efficiency without affecting hemodynamics
Diabetes Management
- For patients with diabetes requiring glycemic control: 1
- Metformin is the preferred initial pharmacologic agent
- Consider combination therapy with other agents based on patient characteristics
Specific Medication Classes and Their Roles
First-Choice Antianginal Agents
- Sublingual or short-acting nitroglycerin, β-blockers, and calcium-channel blockers are traditionally considered first-choice therapy 1
- These recommendations are often based on tradition-driven beliefs rather than contemporary evidence 1
Second-Choice Antianginal Agents
- Ivabradine, nicorandil, ranolazine, and trimetazidine are typically reserved for patients with contraindications to first-choice agents 1
- These newer agents often have more contemporary evidence-based clinical data than traditional first-choice drugs 1, 2
Metabolic Modulators
- Trimetazidine increases cellular tolerance to ischemia by shifting cardiac metabolism from fatty acid to glucose utilization 2
- Unlike traditional antianginals, it doesn't affect oxygen demand but improves metabolic efficiency of ischemic myocytes 2
- Generally well-tolerated with primarily mild gastrointestinal disturbances and minor headaches 1
- Contraindicated in Parkinson's disease and severe renal impairment 1
Important Considerations and Pitfalls
- Avoid combining β-blockers with diltiazem or verapamil due to risk of high-degree atrioventricular block 1
- Ivabradine should not be combined with diltiazem or verapamil (contraindicated) 1
- Nicorandil should not be combined with nitrates due to lack of additional efficacy 3
- Double or triple therapy with different antianginal drug classes is often needed for symptom control 1
- For musculoskeletal pain management, follow a stepped care approach starting with acetaminophen, ASA, or tramadol before considering NSAIDs 1
Special Populations
- For elderly patients with multiple comorbidities, consider drug interactions and reduced organ function when selecting medications 1
- In patients with renal impairment, medication dosages may need adjustment (e.g., metformin can be continued with reduced dosage at GFR of 30-45 mL/min) 1
- For patients with acute exacerbation of chronic bronchitis, azithromycin (500 mg once daily for 3 days) has comparable efficacy to longer courses of other antibiotics 4