From the Guidelines
Microvascular angina should be treated with a personalized approach, prioritizing medications that improve coronary microcirculation, such as ranolazine or ivabradine, in addition to traditional antianginal drugs like beta-blockers and calcium channel blockers. The treatment of microvascular angina is extremely challenging and necessarily empirical, as no conclusive evidence supports a specific class of drugs due to the limited knowledge on the causes of microvascular angina and the variable response to different drug treatments 1.
Key Considerations
- Slowing the heart rate with beta-blockers, diltiazem, verapamil, or ivabradine can be considered due to increased diastolic time and coronary perfusion 1.
- Co-administration of ranolazine or trimetazidine might also be useful in improving symptoms 1.
- In patients with enhanced pain perception, adenosine antagonists and drugs effective in chronic pain syndromes, such as imipramine, are other therapeutic options 1.
- The 2024 ESC guidelines for the management of chronic coronary syndromes suggest a tailored approach to medical therapy, considering the patient's haemodynamic profile, comorbidities, and preferences, as well as the pathophysiological basis of myocardial ischaemia 1.
Treatment Approach
- Initial drug therapy may include a beta-blocker and/or a calcium channel blocker, with other antianginal drugs added on top or as part of initial combination therapy in appropriately selected patients 1.
- Response to initial antianginal therapy should be reassessed, and treatment should be adapted if adequate angina control is not achieved or if the initial treatment is poorly tolerated 1.
- Lifestyle modifications, such as regular moderate exercise, stress reduction techniques, smoking cessation, and maintaining healthy blood pressure and cholesterol levels, are essential in managing microvascular angina.
- Antiplatelet therapy with low-dose aspirin may also be recommended to reduce the risk of cardiovascular events.
From the Research
Diagnosis of Microvascular Angina
- Microvascular angina is defined as angina pectoris caused by abnormalities of small coronary arteries 2
- Diagnosis can be made by invasive or non-invasive methods, including stress tests and coronary angiography 3
- A presumptive diagnosis can also be made based on fulfillment of diagnostic criteria, including anginal chest pain, at least one cardiovascular risk factor, and an abnormal stress test 3
- The Coronary Vasomotion Disorders International Study Group has proposed standardized criteria for diagnosis of microvascular angina using invasive and non-invasive approaches 4
Treatment of Microvascular Angina
- Treatment is initially based on standard anti-ischemic drugs, including beta-blockers, calcium antagonists, and nitrates 2
- Additional drugs with potential anti-ischemic effects, such as ranolazine, ivabradine, and angiotensin-converting enzyme inhibitors, may be used if symptoms persist 2, 5
- Exercise is an effective treatment modality, and aggressive risk factor modification is also recommended 3
- Other treatment options, such as spinal cord stimulation and pain-inhibiting substances, may be considered for patients with refractory microvascular angina 2
- Pharmacological treatment should be based on the characterization of the underlying mechanisms, and individually titrated combinations of antianginal substances may be recommended 6
Management Strategies
- A multifaceted therapeutic approach, including lifestyle changes and intensive pharmacologic secondary prevention, is recommended for managing patients with stable ischemic heart disease, including those with microvascular angina 5
- Current guidelines recommend beta-blockers as first-line treatment, with additional options including nitrates, calcium channel blockers, and ranolazine 5
- Strict risk factor control and individually titrated combinations of antianginal substances are also recommended 6