What are the initial recommendations for managing a patient with angina?

Initial Management of Angina

All patients with angina should immediately receive aspirin 75-100 mg daily and sublingual nitroglycerin for acute symptom relief, combined with aggressive risk factor modification including mandatory smoking cessation, lipid management with statins, blood pressure control, and initiation of beta-blockers or calcium channel blockers for symptom control. 1

Immediate Pharmacological Interventions

Acute Symptom Relief

• Sublingual nitroglycerin is the cornerstone for immediate angina relief 1, 2
• Patients should dissolve one tablet under the tongue at the first sign of anginal pain 2
• The dose may be repeated every 5 minutes up to 3 tablets over 15 minutes 2
• Critical caveat: If pain persists after 3 tablets or differs from typical angina, emergency medical attention is required immediately 2
• Nitroglycerin can be used prophylactically 5-10 minutes before activities that typically trigger angina 2
• Patients should sit when taking nitroglycerin to avoid falls from hypotension 2

Antiplatelet Therapy for Prognostic Benefit

• Aspirin 75-100 mg daily is mandatory for all patients with angina to reduce cardiovascular mortality and morbidity 1
• Clopidogrel 75 mg daily is an acceptable alternative if aspirin is contraindicated 1
• This intervention directly reduces the risk of myocardial infarction and death by preventing acute thrombotic events 1

Regular Antianginal Therapy

First-Line Symptomatic Treatment

• Beta-blockers and/or calcium channel blockers (CCBs) are recommended as initial regular therapy for most patients 1
• The choice between these agents should be guided by comorbidities:
  • Beta-blockers are preferred in patients with prior myocardial infarction, heart failure, or supraventricular arrhythmias 3, 4
  • Calcium channel blockers are preferred when beta-blockers are contraindicated (e.g., asthma, severe bradycardia, high-grade AV block) 3, 4
  • Both drug classes are equally effective for symptom control 1

Important Prescribing Considerations

• Beta-blockers must be tapered over 4 weeks when discontinuing to avoid rebound angina 1
• Patients should be warned never to abruptly stop beta-blockers or allow prescriptions to run out 1
• Long-acting nitrate preparations require a nitrate-free interval (10-12 hours) to prevent tolerance 1
• Nitrate patches should be dosed at least 10 mg for effectiveness 1

Contraindications to Note

• Nitrates are absolutely contraindicated with phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil) due to life-threatening hypotension 1, 2
• Nitrates should not be used in hypertrophic cardiomyopathy 1

Aggressive Risk Factor Modification

Smoking Cessation (Highest Priority)

• Smoking cessation must be strongly emphasized as it directly impacts mortality 1
• Nicotine patches can be safely used in coronary artery disease patients as part of a comprehensive cessation strategy 1

Lipid Management

• All patients require serum cholesterol measurement 1
• Statin therapy should be initiated to achieve LDL-C <70 mg/dL when possible 1
• Drug combinations may be necessary if LDL-C remains >100 mg/dL despite monotherapy 1

Blood Pressure Control

• Blood pressure should be measured and managed according to hypertension guidelines 1
• This is particularly important as hypertension accelerates atherosclerotic progression 1

Weight and Metabolic Management

• Target BMI should be 18.5-24.9 kg/m² 1
• Waist circumference goals: <40 inches (102 cm) for men, <35 inches (89 cm) for women 1
• Initial weight loss goal is 10% reduction from baseline 1
• Diabetes requires appropriate glycemic control 1

Lifestyle Interventions

Exercise Prescription

• Aerobic physical activity of 150-300 minutes per week at moderate intensity or 75-150 minutes at vigorous intensity is recommended 1
• Moderate exercise should be encouraged within the patient's limitations to improve exercise tolerance and reduce symptoms 1
• Medically supervised cardiac rehabilitation programs are beneficial for moderate-to-high-risk patients 1
• Risk assessment, preferably with exercise testing, should guide the exercise prescription 1

Dietary Modifications

• Mediterranean diet with emphasis on vegetables, fruit, fish, and poultry 1
• Fish consumption at least once weekly is recommended 1
• Alcohol in moderation may be beneficial, but excessive consumption is harmful 1

Patient Education Essentials

Critical Information to Convey

• Patients must understand the nature of angina and when to seek emergency care 1
• Alarm symptoms requiring immediate medical attention: angina persisting >10-20 minutes despite rest and nitroglycerin, or pain that differs from typical pattern 1
• Patients should rest briefly from activities that provoke angina 1
• Headache is the most common nitroglycerin side effect and usually diminishes with continued use 5

Medication Storage and Handling

• Nitroglycerin must be kept in the original glass container, tightly capped after each use to maintain potency 2
• Application sites for nitroglycerin patches should be rotated daily to prevent skin irritation 5

Common Pitfalls to Avoid

• Do not combine beta-blockers with non-dihydropyridine calcium channel blockers (verapamil, diltiazem) due to risk of severe bradycardia and heart block 4
• Avoid prescribing nitrates without ensuring the patient is not using PDE-5 inhibitors 1, 2
• Do not use continuous nitrate therapy without a nitrate-free interval, as tolerance will develop 1
• Triple antianginal therapy is often no more effective than dual therapy and may increase adverse effects 4