What is the recommended management for angina?

Management of Angina

All patients with angina should receive aspirin 75-300 mg daily and sublingual nitroglycerin for acute symptom relief, with beta-blockers as first-line regular therapy for symptom control and mortality benefit. 1, 2

Immediate Symptomatic Relief

• Sublingual nitroglycerin (0.3-0.4 mg) should be prescribed to all angina patients for use in response to pain and prophylactically before activities that trigger symptoms 1, 2
• Patients should rest briefly from the provoking activity when angina occurs and be warned about potential hypotension (sit down initially) and headache 1
• If sublingual preparations are ineffective, buccal nitroglycerin should be considered as it is more effective than sublingual 1
• Patients must seek medical attention if angina persists >10-20 minutes after rest or is not relieved by sublingual nitrate 1

First-Line Regular Therapy

Beta-blockers are the recommended first-line agent for regular symptomatic treatment due to their effects on heart rate, contractility, and mortality benefits 2:

• Titrate to full therapeutic dose for maintenance therapy 2
• Use the cheapest preparation the patient can tolerate and comply with that controls symptoms 1
• Critical warning: Never stop beta-blockers abruptly as this causes severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias; taper over 4 weeks if discontinuation is necessary 1, 3
• Beta-blockers reduce oxygen requirements by blocking catecholamine-induced increases in heart rate, myocardial contractility, and blood pressure 3

Second-Line Monotherapy Options

When beta-blockers are contraindicated or not tolerated:

• Long-acting calcium channel blockers should be used as the alternative 2
• Long-acting nitrates can be used, but must be administered with a nitrate-free interval to prevent tolerance 1, 2
• Nitrate patches require dosages of at least 10 mg and must avoid continuous 24-hour coverage 1
• Calcium channel blockers are more effective than placebo for symptom control 1

Combination Therapy Algorithm

If beta-blocker monotherapy at maximal dose is insufficient:

• Add a dihydropyridine calcium channel blocker (e.g., amlodipine) 2
• Avoid short-acting dihydropyridine calcium antagonists unless combined with beta-blockers due to increased risk of adverse cardiac events 2

If patients are not adequately controlled by maximal therapeutic doses of two drugs:

• Remaining evidence-based options are very limited 1
• Refer to cardiology rather than adding a third drug 1, 2
• If a third drug is introduced, monitor its effect closely and discontinue if ineffective 1

Prognostic Medications (Reduce Mortality/Morbidity)

Beyond symptom control, all patients require:

• Aspirin 75-150 mg daily to reduce cardiovascular events 1, 2
• Statins for all patients with documented coronary artery disease 2
• ACE inhibitors in patients with hypertension, heart failure, left ventricular dysfunction, prior myocardial infarction, or diabetes 2

Lifestyle Modifications

• Smoking cessation is mandatory - nicotine patches can safely be used in coronary artery disease patients as part of a broader cessation strategy 1
• Mediterranean diet with vegetables, fruit, fish, and poultry 1
• Physical activity within limitations should be encouraged to increase exercise tolerance and reduce symptoms 1
• Weight reduction for overweight patients 1
• Blood pressure control with target <130/80 mmHg in patients with diabetes or renal disease 1
• Tight glycemic control in diabetic patients 1

Referral Indications

All patients with clinically certain angina should be referred to identify whether they would benefit from prognostic investigation and treatment 1:

• Patients with uncontrolled symptoms on maximal doses of two drugs 1, 2
• Uncertain diagnosis requiring clarification 1
• Pain on minimal exertion 1
• Patients with uncontrolled symptoms should go directly to angiography, not exercise testing 1

Medications to Avoid

• Dipyridamole - can enhance exercise-induced myocardial ischemia 2
• Chelation therapy - lacks evidence 2
• Short-acting dihydropyridine calcium antagonists without beta-blockers - increased adverse cardiac events 2
• COX-2 inhibitors without simultaneous aspirin - should be avoided 1
• Ibuprofen - prevents effective platelet inhibition when combined with aspirin 1

Common Pitfalls

• Failing to provide sublingual nitroglycerin to all angina patients for acute relief 2
• Abruptly discontinuing beta-blockers, which can precipitate myocardial infarction 3
• Using nitrates continuously without a nitrate-free interval, leading to tolerance 1, 2
• Adding a third antianginal drug instead of referring for revascularization evaluation 1
• Not prescribing aspirin and statins for prognostic benefit 2
• Beta-blockers may mask hypoglycemia symptoms in diabetics (though dizziness and sweating remain) 3