What medications are used to manage angina symptoms?

Medications for Angina Symptom Management

Beta-blockers should be used as first-line therapy for angina symptoms, followed by calcium channel blockers or long-acting nitrates when beta-blockers are ineffective or contraindicated, with short-acting nitroglycerin prescribed to all patients for immediate symptom relief. 1, 2

First-Line Medications

• Sublingual nitroglycerin or nitroglycerin spray should be provided to all patients with angina for immediate relief of acute symptoms and for prophylactic use before engaging in activities that might trigger angina 3, 4
• Beta-blockers (e.g., metoprolol, atenolol, bisoprolol) should be titrated to full dose as first-line maintenance therapy for angina symptom control due to their effects on heart rate, contractility, and mortality benefits 3, 1
• Patients should be warned not to stop beta-blockers suddenly as this can worsen angina; they should be tapered off over four weeks if discontinuation is necessary 3

Second-Line Medications

• Long-acting calcium channel blockers (e.g., amlodipine, diltiazem, verapamil) should be used when beta-blockers are contraindicated or ineffective 3
• Long-acting nitrates can be used as an alternative to calcium channel blockers when beta-blockers are contraindicated 3
• When using long-acting nitrates, they must be administered with a nitrate-free interval to prevent nitrate tolerance 3, 2

Combination Therapy

• If beta-blocker monotherapy is insufficient, add a dihydropyridine calcium channel blocker (e.g., amlodipine) 3, 5
• If symptoms are not controlled with two drugs at optimal doses, consider adding a third agent such as ranolazine, but monitor its effect closely 3, 6
• Avoid using short-acting dihydropyridine calcium antagonists when not combined with beta-blockers due to increased risk of adverse cardiac events 3, 2

Special Considerations for Vasospastic Angina

• High-dose calcium channel blockers are the mainstay of treatment for vasospastic angina (up to 480 mg/day verapamil, up to 260 mg/day diltiazem, up to 120 mg/day nifedipine) 3, 7
• Long-acting nitrates may be combined with calcium channel blockers for refractory vasospastic angina 3, 7
• Nicorandil, a potassium channel activator, may be useful in patients with refractory vasospastic angina 3

Medications for Prognostic Benefit

• Aspirin 75-150 mg daily should be prescribed to all patients with coronary artery disease to reduce cardiovascular events 3, 1
• Statins should be prescribed for all patients with documented coronary artery disease to reduce adverse ischemic events 3, 1
• ACE inhibitors should be considered in patients with hypertension, heart failure, left ventricular dysfunction, prior myocardial infarction, or diabetes 3, 1

Medications to Avoid

• Dipyridamole is not recommended as it can enhance exercise-induced myocardial ischemia 3, 1
• Chelation therapy is not recommended due to lack of evidence 3
• Short-acting dihydropyridine calcium antagonists should be avoided unless combined with beta-blockers 3, 2

Common Pitfalls

• Using three anti-anginal drugs simultaneously may provide less symptomatic protection than two drugs at optimal doses 2
• Poor medication adherence is a common cause of treatment failure and should always be assessed 2
• Nitrate tolerance can develop with continuous therapy; ensure proper dosing schedule with nitrate-free intervals (typically overnight) 3, 8
• Patients often have knowledge deficits regarding proper use of sublingual nitroglycerin for both acute relief and prophylaxis 9

When to Consider Referral for Further Management

• Patients whose symptoms are not adequately controlled by maximal therapeutic doses of two drugs should be considered for referral for further treatment or investigation 3
• All patients with clinically certain angina should be referred to identify whether they would benefit from prognostic investigation and treatment 3