What are the initial management recommendations for stable angina?

Initial Management of Stable Angina

First-line management of stable angina should include aspirin 75-100 mg daily, statin therapy, and a beta-blocker (such as bisoprolol 10 mg daily, metoprolol CR 200 mg daily, or atenolol 100 mg daily), along with short-acting nitrates for immediate symptom relief. 1, 2

Diagnostic Approach

• Exercise ECG is the initial non-invasive test of choice to confirm diagnosis and determine prognosis in patients with stable angina with intermediate-to-high pre-test probability 3
• Alternative investigations such as myocardial perfusion scintigraphy and stress echocardiography are valuable when exercise ECG is not possible or interpretable 3
• Echocardiography and other non-invasive imaging modalities help evaluate ventricular function 3
• 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, 1

Pharmacological Management

First-Line Therapy

• Aspirin 75 mg daily should be prescribed for all patients without specific contraindications 3, 2
• Statin therapy is recommended for all patients with stable angina 3, 2
• Beta-blockers should be used as first-line anti-anginal therapy at optimal doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 1, 2
• Short-acting nitrates (sublingual nitroglycerin) are recommended for immediate symptom relief and situational prophylaxis 3, 2

Second-Line Therapy

• If beta-blockers are contraindicated or not tolerated, calcium channel blockers or long-acting nitrates are recommended as alternatives 3, 2
• ACE inhibitors are indicated for patients with coexisting ventricular dysfunction, hypertension, or diabetes 3, 1
• Anti-anginal drug treatment should be tailored to individual needs, with optimization of one drug's dosing before adding another 3
• It is advisable to switch drug combinations before attempting a three-drug regimen 3
• Ranolazine can be considered for patients who remain symptomatic despite treatment with other anti-anginal medications 4

Risk Factor Modification

• Lifestyle modification alongside pharmacological intervention is essential after initial risk evaluation 3
• Strict diabetic control, weight management, smoking cessation, and blood pressure control are strongly advised 3, 1
• Regular physical activity (30-60 minutes daily or at least 3-4 times weekly) is recommended 3
• Target BMI should be between 18.5-24.9 kg/m² 3
• LDL-C target should be less than 70 mg/dL for high-risk patients 3

Revascularization Considerations

• Coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by medical means 3
• PCI is effective for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present 3, 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 3, 2

Common Pitfalls to Avoid

• Using three anti-anginal drugs simultaneously may provide less symptomatic protection than two drugs 2
• Immediate-release or short-acting dihydropyridine calcium antagonists should be avoided as they can increase adverse cardiac events 2
• Poor medication adherence is a common cause of treatment failure and should always be assessed 2
• An attack of angina that does not respond to short-acting nitroglycerin should be regarded as a possible myocardial infarction 2
• Failure to recognize that women may present with atypical symptoms that are less reliable indicators of coronary disease compared to men 3, 1

Follow-Up

• Regular assessment of BMI and waist circumference is recommended 3
• Periodic reassessment of symptoms and medication effectiveness is necessary 3
• Patients should be educated about recognizing changes in symptoms that may indicate unstable angina 2