What is the recommended management for stable angina according to the American Heart Association (AHA) or European Society of Cardiology (ESC) guidelines?

Management of Stable Angina According to ESC Guidelines

According to the European Society of Cardiology guidelines, beta-blockers should be used as first-line therapy for stable angina, followed by calcium channel blockers or long-acting nitrates if beta-blockers are ineffective or contraindicated, with short-acting nitroglycerin prescribed to all patients for immediate symptom relief. 1

Diagnostic Approach

• Exercise ECG is the initial non-invasive test of choice to confirm diagnosis and determine prognosis in patients with stable angina 2
• Alternative investigations such as myocardial perfusion scintigraphy and stress echocardiography are valuable when exercise ECG is not possible or interpretable, or to demonstrate the extent and localization of myocardial ischemia 2
• Echocardiography and other non-invasive imaging modalities help evaluate ventricular function 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 3

Risk Factor Modification

• After initial risk evaluation, lifestyle modification should be implemented alongside pharmacological intervention 2
• Strict diabetic control, weight management, smoking cessation, and blood pressure control are strongly advised for all patients with coronary disease 2
• Successful risk factor management may modify the initial risk assessment 2

Pharmacological Management

For Prognostic Benefit (Class I Recommendations)

• Aspirin 75 mg daily for all patients without specific contraindications 2
• Statin therapy for all patients with coronary disease 2
• ACE inhibitor therapy for patients with hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes 2
• Beta-blockers for post-MI patients or those with heart failure 2

For Symptom Control

• Short-acting nitrates for immediate symptom relief and situational prophylaxis 2, 1
• Beta-blockers as first-line therapy at optimal doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 2, 1
• If beta-blockers are contraindicated or not tolerated, calcium channel blockers or long-acting nitrates are recommended as alternatives 2
• Anti-anginal drug treatment should be tailored to individual needs, with optimization of one drug's dosing before adding another 2
• It is advisable to switch drug combinations before attempting a three-drug regimen 2

Specific Medication Considerations

• Beta-blockers are superior to calcium channel blockers in reducing exercise-induced ischemia as demonstrated in the TIBBS study 2, 1
• Dihydropyridine calcium channel blockers are suitable for combination with beta-blockers 2
• Heart rate-lowering calcium channel blockers may cause conduction disturbances in predisposed patients treated with beta-blockers 2
• Nitrate tolerance can develop with continuous therapy; ensure proper dosing schedule with nitrate-free intervals 1

Revascularization

• Coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by medical means, with a view to revascularization 2
• PCI is effective for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present 2
• CABG is highly effective for symptom relief and reduces mortality risk in specific subgroups, such as left main stem stenosis, proximal LAD stenosis, or three-vessel disease with impaired LV function 2

Common Pitfalls to Avoid

• Using three anti-anginal drugs simultaneously may provide less symptomatic protection than two drugs 1
• Immediate-release or short-acting dihydropyridine calcium antagonists should be avoided as they can increase adverse cardiac events 1
• Poor medication adherence is a common cause of treatment failure and should always be assessed 1
• An attack of angina that does not respond to short-acting nitroglycerin should be regarded as a possible myocardial infarction 2