What is the management of angina pectoris?

Management and Diagnosis of Angina Pectoris

Beta-blockers should be used as first-line therapy for angina pectoris, along with aspirin and statin therapy, with additional medications added in a stepwise approach based on symptom control. 1

Diagnosis

Clinical Evaluation

• Angina pectoris is characterized by substernal chest discomfort typically exacerbated by exertion or emotional stress, lasting 30-60 seconds, and relieved by rest and nitroglycerin 2
• Careful interpretation of chest pain is particularly important in women, as classical symptoms may be less reliable indicators of coronary disease compared to men 1
• Alternative investigations are needed when exercise ECG is not possible or interpretable 1

Diagnostic Testing

• Exercise ECG is the initial non-invasive test of choice to confirm diagnosis and determine prognosis 1
• Myocardial perfusion scintigraphy and stress echocardiography are valuable for demonstrating extent and localization of ischemia 1
• Echocardiography and other imaging modalities like MRI help evaluate ventricular function 1
• Coronary arteriography should be considered when symptoms are not satisfactorily controlled by medical therapy, with a view toward revascularization 3

Management

General Approach

• Treatment aims to improve prognosis by preventing myocardial infarction and death, and to minimize or abolish symptoms 1
• All patients should be evaluated for reversible causes of angina (anemia, hyperthyroidism, sympathomimetic drugs, hypertension) 4
• Risk factor modification through lifestyle changes should be implemented alongside pharmacological intervention 1

Lifestyle Modifications

• Smoking cessation should be strongly encouraged 1
• Adopt a "Mediterranean" diet rich in vegetables, fruits, fish, and poultry 1
• Regular physical activity within patient limitations should be encouraged 1
• Weight reduction for overweight patients 1
• Strict diabetic control and blood pressure management 1

Pharmacological Therapy

First-Line Medications (Class I recommendations)

• Aspirin 75 mg daily for all patients without specific contraindications (active GI bleeding, aspirin allergy) 1
• Statin therapy for all patients with coronary disease 1
• Beta-blockers as first-line anti-anginal therapy 1
  • Target doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 1
  • Metoprolol has been shown effective in controlled clinical trials at doses of 100-400 mg daily 3
• ACE inhibitors in patients with coexisting hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes 1

Additional Anti-anginal Medications

• Short-acting nitrates (sublingual nitroglycerin) for immediate symptom relief and situational prophylaxis 1
  • Patients should be instructed to sit during first use to prevent hypotension 1
  • Angina not responding to short-acting nitroglycerin should be considered a possible myocardial infarction 1
• Long-acting nitrates if beta-blockers are insufficient or contraindicated 1
  • Require a daily "nitrate-free" interval to prevent tolerance 1
  • Can be achieved with appropriate timing of doses or removal of patches for part of the day 1
• Calcium channel blockers (CCBs) as alternative first-line therapy or add-on therapy 1
  • Dihydropyridine CCBs are suitable for combination with beta-blockers 1
  • Rate-lowering CCBs may cause conduction disturbances when combined with beta-blockers 1
• Potassium channel openers (nicorandil) at a usual dose of 20 mg twice daily 1

Optimization of Medical Therapy

• Anti-anginal drug treatment should be tailored to individual needs 1
• Optimize dosing of one drug before adding another 1
• Consider switching drug combinations before attempting a three-drug regimen 1
• If symptoms persist despite optimal medical therapy, consider coronary arteriography for potential revascularization 1

Revascularization

• Percutaneous Coronary Intervention (PCI) is effective for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present 1
• Coronary Artery Bypass Grafting (CABG) is highly effective for symptom relief and may reduce mortality risk in specific subgroups (left main stem stenosis, proximal LAD stenosis, three-vessel disease with impaired LV function) 1

Special Considerations

• Vasospastic (variant) angina is best treated with calcium channel blockers and nitrates 5
• Women may have higher prevalence of coronary artery spasm and "Syndrome X," requiring careful diagnostic evaluation 1
• For refractory angina not responding to standard therapies, consider enhanced external counterpulsation 4

Common Pitfalls and Caveats

• Beta-blockers may worsen symptoms in patients with vasospastic angina 1
• Continuous nitrate therapy leads to tolerance; ensure a daily nitrate-free interval 1
• Calcium channel blockers may precipitate heart failure in predisposed patients 1
• PCI has not been shown to reduce mortality risk compared to medical therapy in stable angina 1
• Despite revascularization, a substantial percentage of patients may have recurrent or continued angina 2