What medications are considered anti-anginal (anti-angina) for the treatment of angina pectoris?

From the Guidelines

Beta-blockers are considered the first-line treatment for angina pectoris, with alternatives including ivabradine, nitrates, and amlodipine for patients who cannot tolerate beta-blockers. The treatment of angina pectoris involves the use of various medications to reduce symptoms and improve quality of life. According to the European Society of Cardiology guidelines 1, beta-blockers are recommended as the preferred first-line treatment to relieve angina, due to their associated benefits of reducing the risk of heart failure hospitalization and premature death.

Some key points to consider when treating angina pectoris include:

• The use of beta-blockers as the first-line treatment, with alternatives such as ivabradine, nitrates, and amlodipine for patients who cannot tolerate beta-blockers 1
• The addition of a second anti-anginal drug, such as ivabradine, nitrates, or amlodipine, when angina persists despite treatment with a beta-blocker or alternative 1
• The consideration of coronary revascularization when angina persists despite treatment with two antianginal drugs 1
• The importance of individualizing treatment based on the patient's specific condition, comorbidities, and angina type, as recommended by the expert consensus document 1

It's also important to note that the choice of medication depends on the patient's specific condition, comorbidities, and angina type. Proper dosing is essential, with nitrates requiring nitrate-free intervals to prevent tolerance. Patients should be educated about potential side effects like headache with nitrates, fatigue with beta-blockers, and edema with calcium channel blockers. The expert consensus document 1 also highlights the importance of considering the patient's comorbidities and the underlying mechanism of disease when selecting antianginal medications. Additionally, the guidelines on the management of stable angina pectoris 1 provide further guidance on the use of other agents, such as sinus node inhibitors and metabolically acting agents, in the treatment of angina pectoris.

From the FDA Drug Label

Ranolazine Extended-Release Tablets is an antianginal indicated for the treatment of chronic angina. In controlled clinical trials, metoprolol, administered orally two or four times daily, has been shown to be an effective antianginal agent, reducing the number of angina attacks and increasing exercise tolerance.

The medications considered anti-anginal for the treatment of angina pectoris are:

• Ranolazine [@\1@]
• Metoprolol [@\2@]

From the Research

Anti-Anginal Medications

The following medications are considered anti-anginal for the treatment of angina pectoris:

• Nitrates, including short-acting nitroglycerin and long-acting nitrates 2, 3, 4, 5
• Beta blockers, which decrease myocardial demand by reducing myocardial contractility, afterload, and heart rate 4, 6
• Calcium channel blockers, which reduce myocardial demand and enhance myocardial oxygen supply 4, 6
• Ranolazine, an inhibitor of the late inward sodium current, which can be used alone or in addition to nitrates or beta blockers 4
• Ivabradine, nicorandil, and trimetazidine, which are approved in Europe for the treatment of angina pectoris, but not in the United States 4

Mechanism of Action

These medications work by:

• Inducing vasodilation in large capacitance blood vessels and increasing epicardial coronary arterial diameter and coronary collateral blood flow (nitrates) 2
• Reducing myocardial demand by decreasing myocardial contractility, afterload, and heart rate (beta blockers) 6
• Enhancing myocardial oxygen supply by reducing afterload and increasing coronary blood flow (calcium channel blockers) 6
• Inhibiting the late inward sodium current (ranolazine) 4

Clinical Use

These medications can be used to:

• Provide rapid therapeutic relief of acute recurrent angina attacks (short-acting nitrates) 2
• Prevent angina and decrease myocardial ischemia (long-acting nitrates and other anti-anginal medications) 3, 4, 5
• Improve exercise tolerance and increase angina-free walking time (nitrates and other anti-anginal medications) 2, 4