What is the appropriate management for a patient with stable angina, hypertension, and hyperlipidemia on propanolol, lisinopril, simvastatin, topiramate, sumatriptan, and aspirin?

Management of Stable Angina with Multiple Comorbidities

This patient's current regimen is appropriate and should be continued with the addition of a thiazide diuretic to optimize cardiovascular risk reduction. 1

Current Medication Assessment

The patient is already on several evidence-based therapies:

• Propranolol (beta-blocker) is correctly prescribed as first-line therapy for stable angina, reducing heart rate, myocardial contractility, and oxygen consumption while providing mortality benefits. 2, 3

• Lisinopril (ACE inhibitor) is appropriately included given the presence of hypertension and coronary artery disease, providing vascular protection and reducing cardiovascular events. 1, 4

• Simvastatin (statin) is essential for all patients with documented coronary artery disease to reduce adverse ischemic events, though high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) should be considered to achieve LDL <70 mg/dL. 2, 4

• Aspirin at 75-150 mg daily is correctly prescribed for all patients with coronary artery disease to reduce cardiovascular events. 2, 4

Critical Addition Required

Add a thiazide diuretic to complete the optimal triple-therapy regimen (beta-blocker + ACE inhibitor + thiazide diuretic) for patients with hypertension and chronic stable angina, which provides Class I evidence for reducing cardiovascular events. 1

Blood Pressure Target

• Target blood pressure should be <130/80 mm Hg due to the presence of coronary artery disease and hypertension. 1, 4

• Blood pressure should be lowered slowly in patients with CAD, and caution is advised when diastolic blood pressure falls below 60 mm Hg, as this may provoke myocardial ischemia. 1

Essential Acute Angina Management

• Sublingual nitroglycerin 0.4 mg must be provided for immediate relief of acute angina episodes, which can be repeated up to 3 doses at 5-minute intervals. 2, 4

• Patients should be instructed to use nitroglycerin prophylactically before activities that might trigger angina. 2

If Angina Remains Uncontrolled

If symptoms persist despite optimal doses of beta-blocker:

• Add a long-acting dihydropyridine calcium channel blocker (such as amlodipine) to the regimen of beta-blocker, ACE inhibitor, and thiazide diuretic. 1

• Avoid combining beta-blockers with nondihydropyridine calcium channel blockers (diltiazem or verapamil) due to increased risk of significant bradyarrhythmias and heart failure. 1

• Long-acting nitrates can be added if calcium channel blockers are insufficient, but must be administered with a nitrate-free interval (10-14 hours) to prevent tolerance development. 1, 2

Critical Safety Considerations

• Never abruptly discontinue propranolol, as this can cause exacerbation of angina and even myocardial infarction; taper over at least 4 weeks if discontinuation is necessary. 2, 5

• Beta-blockers may mask early warning signs of hypoglycemia (such as tachycardia), which is particularly important if the patient develops diabetes or is fasting. 5

• Monitor for signs of heart failure, as beta-blockers can precipitate cardiac failure in susceptible patients, though they are beneficial in well-compensated patients with a history of heart failure. 5

Medications to Avoid

• Do not use short-acting dihydropyridine calcium antagonists unless combined with beta-blockers, as they increase the risk of adverse cardiac events. 2

• Avoid dipyridamole, as it can enhance exercise-induced myocardial ischemia. 2

When to Consider Escalation

• Patients whose symptoms are not adequately controlled by maximal therapeutic doses of two antianginal drugs should be referred for further investigation or revascularization consideration. 2

• Consider stress testing to evaluate the severity of coronary artery disease and effectiveness of anti-ischemic treatment. 4