From the Guidelines
For refractory angina not responding to nitroglycerin, the most effective pain management option is often considered to be calcium antagonists (long-acting) or long-acting nitrates, as they can relieve symptoms without increasing the risk for adverse cardiac events, as suggested by the American College of Physicians guidelines 1.
Key Considerations
- The choice between calcium antagonists and long-acting nitrates should be based on the patient's specific conditions, such as hypertension, and the preferences of both the patient and the treating physician.
- These options may be used in combination with beta-blockers if beta-blockers alone are unsuccessful in managing symptoms, or they may be substituted for beta-blockers if the latter lead to unacceptable side effects.
Management Approach
- Calcium antagonists (long-acting) are often preferable to long-acting nitrates for maintenance therapy due to their sustained 24-hour effects, as noted by the ACC/AHA writing committee 1.
- The management of refractory angina should also include addressing the underlying cause through antiplatelet therapy, anticoagulation, beta-blockers, and possibly urgent cardiac catheterization.
- Oxygen therapy should be provided if oxygen saturation is low, and emergency medical attention should be sought promptly as persistent angina despite nitroglycerin may indicate unstable angina or myocardial infarction.
Recommendations for Pharmacotherapy
- Aspirin or clopidogrel, beta-blockers, low-density lipoprotein cholesterol–lowering therapy with a statin, and ACE inhibitors are recommended for preventing MI or death and reducing symptoms in patients with symptomatic chronic stable angina 1.
- Sublingual nitroglycerin or nitroglycerin spray is recommended for the immediate relief of angina, with calcium antagonists (long-acting) or long-acting nitrates considered for symptom reduction when beta-blockers are contraindicated or unsuccessful.