Should a patient with stable angina discontinue propranolol, lisinopril, simvastatin, topiramate, sumatriptan, venlafaxine (Effexor), or aspirin?

Medication Management in Stable Angina: Which Drugs to Continue

None of these medications should be discontinued in a patient with stable angina—propranolol, lisinopril, simvastatin, and aspirin are all Class I recommendations for reducing mortality and morbidity, while topiramate, sumatriptan, and venlafaxine (Effexor) are unrelated to angina management and should be continued for their respective indications unless contraindicated. 1

Core Medications That Must Be Continued

Beta-Blockers (Propranolol)

• Propranolol should absolutely be continued as beta-blockers are Class I recommendations (Level A evidence for post-MI patients, Level B for those without prior MI) for preventing myocardial infarction and death in stable angina 1
• Beta-blockers reduce cardiovascular death or MI by approximately 30% in post-MI trials and provide both mortality benefit and symptom control 1
• Critical warning: Abrupt discontinuation of propranolol can cause exacerbation of angina and even myocardial infarction 2
• If discontinuation is ever necessary, propranolol must be tapered gradually over at least a few weeks (preferably four weeks) 3, 2
• The FDA label explicitly warns against interruption or cessation without physician supervision 2

ACE Inhibitors (Lisinopril)

• Lisinopril should be continued as ACE inhibitors are Class I recommendations (Level A evidence) for all patients with stable angina and proven coronary disease 1
• The HOPE study demonstrated that ACE inhibitors reduce cardiovascular death, MI, and stroke in patients with vascular disease, with benefits extending beyond blood pressure reduction 1
• ACE inhibitors provide particular benefit in patients with diabetes, hypertension, heart failure, or left ventricular dysfunction 1

Statins (Simvastatin)

• Simvastatin should be continued as statin therapy is a Class I recommendation (Level A evidence) for all patients with coronary disease 1
• Multiple trials (Heart Protection Study, CARE, LIPID) demonstrate that statins decrease adverse ischemic events in patients with established coronary artery disease 1
• Statins should be used even with mild to moderate LDL cholesterol elevations in patients with stable angina 1

Antiplatelet Therapy (Aspirin)

• Aspirin should be continued as it is a Class I recommendation (Level A evidence) for all patients with stable angina without contraindications 1
• Aspirin 75-150 mg daily reduces vascular events, with doses of 75-325 mg showing similar efficacy 1, 3
• The only absolute contraindications are active GI bleeding, aspirin allergy, or previous aspirin intolerance 1

Medications Unrelated to Angina Management

Topiramate, Sumatriptan, and Venlafaxine (Effexor)

• These medications should be continued for their respective indications (migraine prophylaxis/treatment and depression/anxiety) as they are not part of stable angina management 1
• None of these medications are contraindicated in stable angina patients
• These drugs serve separate therapeutic purposes and discontinuation would only be warranted based on their own risk-benefit profiles for their intended conditions

Clinical Algorithm for Medication Review

Step 1: Confirm all four core medications are present

• Beta-blocker (propranolol) ✓
• ACE inhibitor (lisinopril) ✓
• Statin (simvastatin) ✓
• Aspirin ✓

Step 2: Verify appropriate dosing

• Propranolol should be titrated to full therapeutic dose for symptom control 3
• Aspirin 75-325 mg daily 1
• Statin at appropriate intensity based on risk 1

Step 3: Assess for contraindications

• Propranolol: avoid in severe bradycardia, high-degree AV block, decompensated heart failure, or severe bronchospasm 2, 4
• Aspirin: avoid only with active bleeding, allergy, or documented intolerance 1

Step 4: Continue non-cardiac medications

• Maintain topiramate, sumatriptan, and venlafaxine for their respective indications unless separate contraindications exist

Common Pitfalls to Avoid

• Never abruptly stop beta-blockers: This is the single most dangerous action, as it can precipitate acute coronary syndrome 3, 2
• Do not discontinue statins based on mild LDL elevations: Statins provide benefit across a wide range of cholesterol levels in CAD patients 1
• Avoid confusing symptom control with prognostic benefit: While propranolol helps with symptoms, its primary value is in reducing mortality and MI risk 1
• Do not assume all medications in a cardiac patient are for angina: Recognize that topiramate, sumatriptan, and venlafaxine serve different purposes and should not be discontinued without separate indication 1