What is the management of stable angina?

Management of Stable Angina

The management of stable angina requires a comprehensive pharmacological approach with beta-blockers as first-line therapy, followed by calcium channel blockers or long-acting nitrates, while ensuring all patients receive sublingual nitroglycerin for immediate symptom relief and medications for prognostic benefit including aspirin, statins, and ACE inhibitors. 1

Pharmacological Management for Symptom Control

First-Line Therapy

• Beta-blockers (e.g., metoprolol, atenolol, bisoprolol) should be initiated and titrated to optimal dose as they effectively reduce heart rate, myocardial contractility, and oxygen consumption 2, 1
• All patients should receive sublingual nitroglycerin or nitroglycerin spray for immediate relief of angina attacks 2
• Beta-blockers are superior to calcium channel blockers in reducing exercise-induced ischemia 1, 3

Second-Line Therapy (when beta-blockers are contraindicated or ineffective)

• Long-acting calcium channel blockers (non-dihydropyridines like diltiazem, verapamil or long-acting dihydropyridines like amlodipine) 2
• Long-acting nitrates (with nitrate-free intervals to prevent tolerance) 2

Combination Therapy

• Add calcium channel blockers or long-acting nitrates to beta-blockers when monotherapy is insufficient for symptom control 2
• Ranolazine can be considered as add-on therapy for patients with persistent symptoms despite optimal doses of first and second-line medications 4, 5

Medications for Prognostic Benefit

• Aspirin 75-150 mg daily (or clopidogrel when aspirin is contraindicated) to reduce risk of myocardial infarction and death 2, 1
• Statins for all patients with stable angina regardless of baseline cholesterol levels 2
• ACE inhibitors, particularly in patients with:
  • Previous myocardial infarction
  • Left ventricular dysfunction
  • Diabetes
  • Hypertension 2

Special Considerations

Vasospastic Angina

• High-dose calcium channel blockers are the mainstay of treatment (up to 480 mg/day verapamil, up to 260 mg/day diltiazem, up to 120 mg/day nifedipine) 1
• Long-acting nitrates can be added for additional symptom control 2

Microvascular Angina

• Beta-blockers combined with ACE inhibitors and statins are recommended 1, 3
• Calcium channel blockers may be effective in some patients 2

Revascularization Considerations

• Consider revascularization when:

  • Symptoms persist despite optimal medical therapy (two or more anti-anginal drugs at optimal doses) 2, 1
  • High-risk coronary anatomy is present (left main disease, three-vessel disease, or two-vessel disease with proximal LAD involvement) 2, 6
  • Left ventricular dysfunction is present 1

• Percutaneous coronary intervention (PCI):

  • Effective for symptom control in patients with suitable coronary anatomy 2
  • May not provide survival benefit over optimal medical therapy in stable angina 2, 5

• Coronary artery bypass grafting (CABG):

  • Improves survival in patients with left main disease, three-vessel disease, or two-vessel disease with proximal LAD stenosis 6
  • More durable symptom relief compared to PCI but with higher initial procedural risk 2, 6

Common Pitfalls to Avoid

• Using immediate-release or short-acting dihydropyridine calcium antagonists, which can increase adverse cardiac events 2
• Failing to provide nitrate-free intervals when using long-acting nitrates, leading to tolerance 2, 1
• Using three anti-anginal drugs simultaneously may provide less symptomatic protection than optimizing two drugs 1
• Neglecting to address modifiable risk factors (smoking, diabetes, hypertension, hyperlipidemia) 2, 7
• Failing to assess medication adherence when symptoms persist despite seemingly adequate therapy 1
• Not instructing patients to seek emergency care if angina does not respond to nitroglycerin, which may indicate myocardial infarction 1

Monitoring and Follow-up

• Regular assessment of symptom control and medication side effects 6
• Periodic evaluation of exercise capacity and functional status 2
• Reassessment of risk factors and optimization of their management 2, 7
• Consideration of non-invasive testing for patients with changing symptom patterns 2