What medications help with angina?

Medications for Management of Angina

Beta-blockers should be the first-line medication for angina treatment, followed by calcium channel blockers if beta-blockers are not tolerated or ineffective, with short-acting nitrates used 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 for situational prophylaxis before activities that might trigger angina 1, 2
• Patients should be instructed on proper use: take as needed for pain and before engaging in activities that may trigger angina 1
• If sublingual preparations are ineffective, buccal preparations can be considered as they may be more effective 1
• An attack of angina that does not respond to short-acting nitroglycerin should be considered a possible myocardial infarction 1

Beta-Blockers

• Beta-blockers should be tested as first-line regular treatment for angina, titrated to full dose 1, 2
• Beta-1 selective agents (metoprolol, atenolol, bisoprolol) are preferred due to fewer side effects compared to non-selective beta-blockers 1
• Target doses for full 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 over four weeks 1
• Common side effects include cold extremities, bradycardia, and increased respiratory symptoms (less common with beta-1 selective agents) 1

Second-Line Medications

Calcium Channel Blockers (CCBs)

• If beta-blockers are not tolerated or ineffective, calcium channel blockers should be used as monotherapy 1
• For patients inadequately controlled on beta-blockers, add a dihydropyridine calcium channel blocker 1
• 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
• All CCBs may precipitate heart failure in predisposed patients 1

Long-Acting Nitrates

• Long-acting nitrates can be used if beta-blockers or calcium channel blockers are not tolerated or effective 1
• Nitrate patches should be used in dosages of at least 10 mg 1
• To avoid nitrate tolerance, patients should have a "nitrate-free" interval each day 1, 3
• For transdermal patches, remove during part of the day or at night 1
• For oral nitrates, use appropriate timing of doses 1

Other Agents

• Nicorandil (potassium channel opener) may be used if other agents are not tolerated or effective 1
• Metabolic agents (trimetazidine, ranolazine) can be used as add-on therapy or substitution when conventional drugs are not tolerated 1, 4
• Ivabradine (sinus node inhibitor) may be considered if beta-blockers are not tolerated 1, 4

Treatment Algorithm

1. For all patients: Provide short-acting sublingual nitroglycerin for acute symptom relief 1
2. First-line regular treatment: Beta-blocker (optimize dose before adding another drug) 1, 2
3. If beta-blocker intolerant or ineffective: Try calcium channel blocker monotherapy 1
4. If symptoms persist on beta-blocker: Add dihydropyridine calcium channel blocker 1
5. If CCB monotherapy or combination therapy is unsuccessful: Substitute with long-acting nitrate or nicorandil (avoid nitrate tolerance) 1
6. For refractory symptoms: Consider metabolic agents as add-on therapy 1, 4

Special Considerations

Vasospastic Angina

• Calcium channel blockers are more effective than beta-blockers for vasospastic angina 1
• High doses of calcium channel blockers may be needed (up to 480 mg/day verapamil, up to 260 mg/day diltiazem, up to 120 mg/day nifedipine) 1
• Beta-blockers may worsen symptoms in patients with vasospastic angina 1
• In refractory cases, combination therapy with long-acting nitrates and high-dose calcium channel blockers is recommended 1, 5

Common Pitfalls

• Nitrate tolerance: Ensure patients have a daily nitrate-free interval when using long-acting nitrates 1, 3
• Beta-blocker discontinuation: Abrupt cessation can cause rebound angina; taper over 4 weeks 1
• Overmedication: Three anti-anginal drugs may provide less symptomatic protection than two drugs; optimize dosing of one drug before adding another 1
• Poor adherence: Always consider this when drug therapy is unsuccessful 1

Additional Recommendations

• All patients should be treated with aspirin 75-300 mg daily unless contraindicated 1, 2
• Consider statin therapy for all patients with angina 2
• ACE inhibitors are recommended for patients with CAD, particularly beneficial in those with diabetes 2