What is the recommended management for stable angina?

Management of Stable Angina

All patients with stable angina should receive aspirin 75 mg daily, statin therapy, and beta-blockers as first-line pharmacological treatment, combined with aggressive risk factor modification including smoking cessation, Mediterranean diet, and regular physical activity. 1, 2

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis through structured testing:

• Exercise ECG is the initial test of choice for patients with intermediate-to-high pre-test probability who can exercise and have interpretable baseline ECGs 3, 2
• Stress imaging (myocardial perfusion scintigraphy or stress echocardiography) should be used when exercise ECG is non-diagnostic, uninterpretable (e.g., baseline ST changes, LBBB, paced rhythm), or when localization of ischemia is needed 3, 2
• Interpret chest pain carefully in women, as classical anginal symptoms are less reliable indicators of coronary disease compared to men 1, 2

Risk Factor Modification (Disease-Modifying Strategy)

These interventions reduce mortality and MI risk—they are not optional:

• Smoking cessation is mandatory 3, 1
• Mediterranean diet with fish consumption at least weekly 3, 1
• Regular physical activity within patient limitations to increase exercise tolerance and improve metabolic parameters 3
• Blood pressure control to <130/80 mmHg in patients with diabetes or renal disease, and <130/85 mmHg in those with established coronary disease 3
• Strict glycemic control in diabetics with multifactorial intervention addressing all cardiovascular risk factors 3, 1
• Weight reduction for overweight patients 1

First-Line Pharmacological Therapy (Prognostic Benefit)

These medications improve outcomes and should be prescribed unless contraindicated:

Antiplatelet Therapy

• Aspirin 75 mg daily for all patients without contraindications 1, 2
• Clopidogrel 75 mg daily is an alternative for aspirin-intolerant patients, though gastrointestinal bleeding risk is only marginally lower 3

Lipid Management

• Statin therapy for all patients regardless of baseline cholesterol 1, 2

Beta-Blockers (Dual Benefit: Symptoms + Prognosis)

• Beta-blockers are first-line anti-anginal therapy with proven mortality benefit post-MI and in heart failure 1, 2
• Target doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 1, 2
• All beta-blockers appear equally effective for symptom control 4

ACE Inhibitors

• Recommended for patients with: hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes 1, 2

Anti-Anginal Symptom Management

Immediate Relief

• Short-acting sublingual nitroglycerin for acute symptom relief and situational prophylaxis (e.g., before exertion or sexual activity) 3, 1, 2
• Instruct patients to sit during first use to prevent hypotension 1
• An attack not responding to nitroglycerin should be treated as possible MI 2

Chronic Symptom Control Algorithm

Step 1: Optimize Beta-Blocker Monotherapy

• Titrate to target doses before adding second agent 2
• If contraindicated (e.g., severe bradycardia, high-grade AV block, bronchospasm) or not tolerated, proceed to calcium channel blockers 2, 4

Step 2: Add or Switch to Calcium Channel Blocker

• Long-acting dihydropyridines or non-dihydropyridines are equally effective as beta-blockers 4
• Avoid immediate-release or short-acting dihydropyridines as they increase adverse cardiac events 2
• Can combine with beta-blocker if monotherapy insufficient 2

Step 3: Add Long-Acting Nitrates (Third-Line)

• Require nitrate-free interval to prevent tolerance 4
• All long-acting nitrates equally effective 4

Step 4: Consider Ranolazine for Refractory Symptoms

• Ranolazine 500-1000 mg twice daily reduces angina frequency and nitroglycerin use when added to maximum antianginal therapy 5
• In the CARISA trial, ranolazine added to atenolol, amlodipine, or diltiazem significantly increased exercise duration and time to angina (p<0.05) 5
• In the ERICA trial, ranolazine 1000 mg twice daily added to amlodipine 10 mg daily significantly decreased angina attacks (p=0.028) and nitroglycerin use (p<0.05) 5

Critical Pitfalls to Avoid

• Do not use three anti-anginal drugs simultaneously—this provides less symptomatic benefit than two-drug regimens 2
• Switch drug combinations before attempting three-drug therapy 2
• Assess medication adherence before escalating therapy, as poor compliance is a common cause of treatment failure 2
• Avoid unopposed COX-2 inhibitors (e.g., celecoxib without aspirin) in stable angina patients 3
• If NSAIDs are needed, avoid ibuprofen as it blocks aspirin's antiplatelet effect; diclofenac can be used with aspirin 3

Revascularization Indications

When to Refer for Coronary Angiography

• Symptoms not satisfactorily controlled by optimal medical therapy 2
• Tolerance to medical therapy did not develop in trials, so true refractory angina warrants invasive evaluation 5

PCI (Percutaneous Coronary Intervention)

• Effective for anatomically suitable lesions in patients with inadequate symptom control on medications 1, 2
• Does not reduce mortality or MI compared to medical therapy in stable disease, but superior for symptom relief 6

CABG (Coronary Artery Bypass Grafting)

• Provides both symptom relief AND mortality benefit in specific high-risk subgroups 1, 2:
  • Left main stem stenosis
  • Proximal LAD stenosis
  • Three-vessel disease with impaired LV function
• 80% remain angina-free at 5 years post-CABG 4
• Initially more effective than medical therapy for symptoms, but outcomes converge at 5-10 years 4

Special Considerations

Concomitant Conditions

• Correct anemia and hyperthyroidism if present, as these exacerbate angina 3
• Diabetes requires multifactorial intervention with near-normal glucose control and aggressive management of all cardiovascular risk factors 3

Elderly Patients

• Anti-anginal medications, statins, and revascularization are equally effective in elderly as in younger patients 3
• Monitor for polypharmacy and drug interactions 3

Chronic Refractory Angina

• Defined as symptoms despite maximal medical therapy, CABG, and PCI with exclusion of non-cardiac causes 3
• Consider enhanced external counterpulsation, spinal cord stimulation, or transmyocardial revascularization, though these require further validation 6