What medications help with angina?

Medications for Angina Management

Beta-blockers should be the first-line medication for angina, followed by calcium channel blockers if beta-blockers are not tolerated or effective, and nitrates for immediate symptom relief. 1

First-Line Medications

Short-Acting Nitrates

• Sublingual nitroglycerin (glyceryl trinitrate) should be provided to all patients for immediate relief of acute angina symptoms and situational prophylaxis 1
• Patients should be instructed to use sublingual nitroglycerin before engaging in activities that may trigger angina 1
• If patients don't respond to sublingual preparations, buccal nitroglycerin should be considered as it may be more effective 1

Beta-Blockers

• Beta-blockers should be tested as first-line regular treatment for angina and titrated to full dose 1, 2
• Beta-1 selective agents (metoprolol, atenolol, bisoprolol) are preferred due to fewer side effects 1
• Target doses for optimal anti-anginal effects: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, atenolol 100 mg daily 1
• Patients should be warned not to stop beta-blockers suddenly; they should be tapered off over four weeks 1
• Common side effects include cold extremities, bradycardia, and potential respiratory symptoms in asthma/COPD patients 1

Second-Line Medications

Calcium Channel Blockers (CCBs)

• If beta-blockers are not tolerated or effective, calcium channel blockers should be used as monotherapy 1
• For insufficient response to beta-blocker monotherapy, add a dihydropyridine calcium channel blocker 1, 2
• Dihydropyridine CCBs (like amlodipine, nifedipine) are suitable for combination with beta-blockers 1
• Heart rate-lowering CCBs (verapamil, diltiazem) may cause conduction disturbances in patients already on beta-blockers 1

Long-Acting Nitrates

• Long-acting nitrates reduce frequency and severity of anginal attacks 1
• Must be administered with a "nitrate-free" interval each day to avoid tolerance 1
• For transdermal patches, remove at night and apply a new patch in the morning 3
• Nitrate patches should be used in dosages of at least 10 mg 1

Additional Treatment Options

Nicorandil

• A potassium channel activator with nitrate-like effects 1
• Can be used if beta-blockers or calcium channel blockers are not tolerated 1
• Usual dose is 20 mg twice daily for angina prevention 1

Ranolazine

• Indicated for chronic angina treatment 4
• Can be used with beta-blockers, nitrates, calcium channel blockers, and other cardiovascular medications 4
• Effective in reducing angina frequency and nitroglycerin use in patients who remain symptomatic despite maximum doses of other anti-anginal agents 4
• Available in extended-release tablets at doses of 500-1000 mg twice daily 4

Treatment Algorithm

1. Start with sublingual nitroglycerin for immediate relief of symptoms 1
2. Initiate beta-blocker therapy and titrate to full dose 1
3. If beta-blocker is not tolerated or ineffective:
   • Switch to calcium channel blocker monotherapy 1, OR
   • Try long-acting nitrates 1, OR
   • Consider nicorandil 1
4. If symptoms persist on beta-blocker monotherapy:
   • Add a dihydropyridine calcium channel blocker 1
5. If symptoms persist on two-drug therapy:
   • Consider adding a third drug (long-acting nitrate or ranolazine) 1, 4
   • Monitor effect of third drug and discontinue if ineffective 1

Special Considerations

Vasospastic Angina

• Calcium channel blockers at high doses (up to 480 mg/day verapamil, up to 260 mg/day diltiazem, up to 120 mg/day nifedipine) are more effective than nitrates for prevention 1, 5
• A combination of long-acting nitrates and high-dose calcium channel blockers is often needed 1
• Nicorandil may be useful in refractory cases 1

Common Pitfalls

• Nitrate tolerance develops with continuous use; ensure a nitrate-free interval daily 1, 6
• Cross-tolerance between different nitrate preparations can occur 6
• Beta-blockers may worsen symptoms in patients with vasospastic angina 1
• Avoid abrupt discontinuation of beta-blockers as this can cause rebound angina 1
• When using multiple anti-anginal drugs, optimize the dose of one drug before adding another 1