What is the initial management for a patient presenting with angina?

Initial Management of Angina

For a patient presenting with angina, immediately administer sublingual nitroglycerin (0.3-0.4 mg) and assess response within 3-5 minutes; if pain is unimproved or worsening, call 9-1-1 to activate emergency medical services, as this may represent an acute coronary syndrome requiring urgent evaluation. 1

Immediate Assessment and Stabilization

First-Line Acute Management

• Administer sublingual nitroglycerin (0.3-0.4 mg) or spray immediately for chest discomfort 1
• If pain persists after 5 minutes or worsens, activate emergency medical services (call 9-1-1) immediately rather than repeating nitroglycerin 1
• For patients with chronic stable angina whose symptoms significantly improve after one dose, it is reasonable to repeat nitroglycerin every 5 minutes for maximum of 3 doses before calling 9-1-1 if symptoms have not totally resolved 1
• Place patient on continuous ECG monitoring to detect ischemia and arrhythmias 1
• Administer supplemental oxygen if cyanosis, respiratory distress, or oxygen saturation <90% is present 1

Risk Stratification

• Obtain 12-lead ECG within 10 minutes of presentation to distinguish ST-elevation MI from non-ST-elevation acute coronary syndrome 1
• Patients with ongoing rest pain lasting >20 minutes, hemodynamic instability, or recent syncope require immediate emergency department referral 1
• High-risk features include: transient ST-segment changes >0.5 mm, new or worsening mitral regurgitation, pulmonary edema, hypotension, or elevated cardiac biomarkers 1

Hospital-Based Initial Management

Pharmacologic Therapy for Acute Presentation

• Nitroglycerin: Start with sublingual administration, followed by intravenous infusion for ongoing ischemia (starting at 10 mcg/min, titrating upward) 1, 2
• Morphine sulfate intravenously when symptoms are not immediately relieved with nitroglycerin or when acute pulmonary congestion/severe agitation is present 1
• Beta-blocker: Administer first dose intravenously if ongoing chest pain is present, followed by oral administration, unless contraindicated (severe bradycardia, heart block, decompensated heart failure, or active bronchospasm) 1, 3
• Aspirin: Initiate 162-325 mg immediately (non-enteric coated for faster absorption), then continue 81 mg daily indefinitely 1

Important Contraindications and Precautions

• Do not administer nitroglycerin within 24 hours of sildenafil (Viagra) use, 48 hours of tadalafil (Cialis), or while taking vardenafil (Levitra) due to risk of severe hypotension 1, 4
• Avoid immediate-release dihydropyridine calcium channel blockers (e.g., nifedipine) in the absence of beta-blocker therapy 1
• Do not abruptly discontinue beta-blockers in patients with coronary artery disease, as this can precipitate severe exacerbation of angina, myocardial infarction, or ventricular arrhythmias; taper over 1-2 weeks if discontinuation is necessary 3

Ongoing Symptomatic Management

Regular Anti-Anginal Therapy

• Beta-blockers are first-line for regular symptomatic treatment in patients requiring ongoing therapy 1
• Calcium channel blockers (verapamil or diltiazem for rate control; amlodipine for additional vasodilation) are effective as monotherapy or in combination with beta-blockers 1, 5
• Long-acting nitrates (oral or transdermal patches ≥10 mg) should be used with a nitrate-free interval to avoid tolerance 1, 4
• For patients inadequately controlled on two drugs at maximal doses, consider adding ranolazine as third-line therapy 6

Patient Education and Discharge Planning

• Provide sublingual nitroglycerin with written and verbal instructions: take one dose immediately for angina, and if pain is unimproved or worsening after 5 minutes, call 9-1-1 1
• Instruct patients to use nitroglycerin prophylactically before activities known to precipitate angina 1
• Educate about warning signs requiring immediate medical attention: angina that is more frequent, more severe, precipitated by less effort, or occurs at rest 1
• Emphasize cardiovascular risk factor modification: smoking cessation, blood pressure control, lipid management with statins, and regular exercise 1

Common Pitfalls to Avoid

• Patients often delay calling emergency services while self-medicating with multiple nitroglycerin doses; emphasize the 5-minute rule for calling 9-1-1 1
• Many patients are not prescribed sublingual nitroglycerin despite confirmed coronary disease; ensure all angina patients have access to this medication 7
• Nitrate tolerance develops with continuous exposure; always use a nitrate-free interval (typically 10-12 hours overnight) with long-acting preparations 1, 4
• Beta-blocker withdrawal can be catastrophic in coronary disease patients; warn patients never to abruptly stop or allow prescriptions to run out 1, 3