What is the recommended management for angina?

Management of Angina

The recommended first-line management for angina includes sublingual nitroglycerin for acute relief, aspirin 75-150mg daily for all patients, and beta-blockers as initial regular therapy, followed by calcium channel blockers or long-acting nitrates if symptoms persist. 1

Acute Symptom Relief

• Provide short-acting sublingual nitroglycerin (0.3-0.4mg) for immediate relief of anginal episodes and as prophylaxis before activities that may trigger angina 1, 2
• Instruct patients to take nitroglycerin when pain occurs and to sit down during first use to avoid hypotension 1
• If sublingual preparations are ineffective, consider buccal nitroglycerin which may be more effective 1
• Patients should seek medical attention if pain persists >10-20 minutes after rest and nitroglycerin 1

Regular Preventive Therapy

First-Line Medications

• Beta-blockers (e.g., metoprolol) should be initiated and titrated to full dose as first-line regular therapy 1, 3

  • Provide 24-hour protection against ischemia 1
  • Warning: Never stop beta-blockers suddenly; taper over 4 weeks to avoid rebound effects 1
  • Relative contraindications include asthma and symptomatic peripheral vascular disease 1

• Aspirin 75-300mg daily for all patients to reduce risk of vascular events 1

Second-Line or Add-On Therapy

• If beta-blockers are ineffective or not tolerated, use calcium channel blockers (e.g., amlodipine) as monotherapy 1, 4

  • Amlodipine 5-10mg daily has demonstrated effectiveness in exercise-induced angina, with increases in exercise time of 7.9-12.8% 4

• For patients not adequately controlled on beta-blocker monotherapy, add a dihydropyridine calcium channel blocker 1

• Long-acting nitrates can be used as monotherapy if beta-blockers and calcium channel blockers are not tolerated, or as add-on therapy 1

  • Nitrate patches should be used in dosages of at least 10mg 1
  • Important: Use nitrates in a way that avoids tolerance (provide a daily nitrate-free interval) 1

Special Considerations

Vasospastic Angina

• Calcium channel blockers are particularly effective for vasospastic (Prinzmetal's) angina, often requiring high doses 5
• Combination therapy with long-acting nitrates and calcium channel blockers is often needed for optimal control 5

Refractory Angina

• If symptoms are not controlled with two drugs at optimal doses, consider referral to a cardiologist rather than adding a third drug 1
• Patients with uncontrolled symptoms should be referred for angiography, not exercise testing 1

Lifestyle Modifications

• Strongly encourage smoking cessation in all patients who smoke 1

  • Nicotine replacement therapy can be safely used in patients with coronary artery disease 1

• Control hypertension according to current guidelines 1

• Advise adoption of a "Mediterranean" diet rich in vegetables, fruits, fish, and poultry 1

• Encourage appropriate physical activity within patient limitations 1

Referral Criteria

• Refer all patients with clinically certain angina to identify those who would benefit from prognostic investigation and treatment 1

• Consider referral for patients with:

  • Uncertain diagnosis 1
  • Suboptimal symptom control despite medical therapy 1
  • Symptoms uncontrolled on two drugs at optimal doses 1

Common Pitfalls to Avoid

• Failure to prescribe sublingual nitroglycerin for all patients with suspected or confirmed coronary artery disease 2

• Inadequate patient education about proper dosage and administration of sublingual nitroglycerin 2

• Abrupt discontinuation of beta-blockers, which can worsen angina and precipitate cardiac events 1

• Failure to provide a nitrate-free interval when using long-acting nitrates, leading to tolerance 1

• Continuing ineffective medications rather than monitoring response and discontinuing if ineffective 1