What is the recommended management for angina?

Management of Angina

All patients with angina should receive short-acting sublingual nitroglycerin for immediate symptom relief, aspirin 75-150 mg daily, a statin, and a beta-blocker as first-line anti-anginal therapy, with systematic escalation to combination therapy if symptoms persist. 1, 2

Immediate Symptomatic Relief

• Provide sublingual nitroglycerin (or nitroglycerin spray) to all patients for acute symptom relief and situational prophylaxis before activities that trigger angina. 1, 2
• If sublingual preparations are ineffective, consider buccal nitroglycerin preparations, which demonstrate superior efficacy. 1
• Instruct patients that angina unresponsive to short-acting nitroglycerin should be treated as a possible myocardial infarction. 2

Prognostic Medications (Reduce Mortality and Morbidity)

These medications improve survival and must be initiated in all patients without contraindications:

• Aspirin 75-150 mg daily reduces subsequent vascular events and mortality. 1, 2
• Clopidogrel 75 mg daily is an alternative only when aspirin is absolutely contraindicated. 1
• Statin therapy regardless of baseline cholesterol levels, as it reduces mortality. 1, 2
• ACE inhibitor for patients with proven cardiovascular disease, particularly those with hypertension, heart failure, left ventricular dysfunction, prior MI with LV dysfunction, or diabetes. 1, 2

First-Line Anti-Anginal Therapy

Beta-blockers are the preferred first-line anti-anginal agent due to mortality benefits in post-MI patients and proven symptom control efficacy. 1, 3, 2

• Titrate beta-blockers to achieve a resting heart rate of 55-60 bpm for optimal anti-anginal effect. 3
• Target doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily. 2
• Critical warning: Never abruptly discontinue beta-blockers in patients with coronary artery disease—taper over 1-2 weeks to avoid severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. 4, 1
• Beta-blockers are contraindicated in sick sinus syndrome, atrioventricular conduction disorders, and should be used cautiously in peripheral arterial disease and chronic obstructive pulmonary disease. 3
• Diabetes is not a contraindication; diabetic patients benefit equally or more from beta-blocker therapy. 2

Second-Line Therapy (Beta-Blocker Intolerance or Contraindication)

If beta-blockers are contraindicated or not tolerated:

• Substitute with a calcium channel blocker (long-acting), long-acting nitrate, or nicorandil as monotherapy. 1, 2
• For vasospastic angina specifically, dihydropyridine calcium channel blockers are first-line therapy at high doses (up to 480 mg/day verapamil, 260 mg/day diltiazem, or 120 mg/day nifedipine). 1
• Ivabradine (a sinus node inhibitor) may be considered as an alternative in beta-blocker intolerance. 1

Combination Therapy (Inadequate Response to Monotherapy)

If beta-blocker monotherapy at optimal doses fails to control symptoms, add a dihydropyridine calcium channel blocker (e.g., amlodipine). 1, 3, 2

• Critical pitfall: Avoid combining non-dihydropyridine calcium channel blockers (verapamil, diltiazem) with beta-blockers due to risk of excessive bradycardia and negative inotropic effects, especially in heart failure. 3, 2
• If calcium channel blocker plus beta-blocker combination therapy is unsuccessful, substitute the calcium channel blocker with a long-acting nitrate or nicorandil. 1
• When using long-acting nitrates, provide a daily "nitrate-free" interval of 10-12 hours to prevent tolerance—typically remove patches at bedtime and reapply in the morning. 1, 3, 5

Third-Line Add-On Therapy

If symptoms persist despite two optimally dosed anti-anginal drugs:

• Consider ranolazine, nicorandil, or trimetazidine as add-on therapy. 3, 2
• Ivabradine should be considered specifically in patients with left ventricular systolic dysfunction, inadequate symptom control, or heart rate >70 bpm despite beta-blocker therapy. 3
• For microvascular angina, ranolazine and trimetazidine are particularly effective. 3
• Metabolic agents may be used as add-on or substitution therapy when conventional drugs are not tolerated. 1

Important: Optimize the dosing of one drug before adding another—three-drug regimens may provide less symptomatic protection than two drugs. 1, 2

When to Refer for Revascularization

• Refer patients to cardiology for angiography (not exercise testing) when symptoms remain uncontrolled despite full doses of two anti-anginal drugs. 1, 2
• All patients with clinically certain angina should be referred to identify whether they fall into a group that would benefit from prognostic investigation and treatment. 1
• Coronary revascularization (PCI or CABG) is indicated when angina is not satisfactorily controlled by medical means. 2

Risk Factor Modification

• Smoking cessation is essential—nicotine patches can safely be used in patients with coronary artery disease as part of a broader cessation strategy. 1, 2
• Strict diabetic control, weight management, and blood pressure control are strongly advised. 2
• Lifestyle modification should accompany pharmacological intervention. 2

Common Pitfalls to Avoid

• Poor medication adherence is a common cause of treatment failure—always assess compliance before escalating therapy. 1, 2
• Avoid immediate-release or short-acting dihydropyridine calcium antagonists, which increase adverse cardiac events. 1, 2
• Do not combine ivabradine with non-dihydropyridine calcium channel blockers or strong CYP3A4 inhibitors. 2
• Avoid combining nicorandil with nitrates, as it lacks additional efficacy. 2
• Beta-blockers may mask tachycardia from hypoglycemia in diabetic patients, though other manifestations (dizziness, sweating) remain. 4
• In pheochromocytoma, beta-blockers must be given only after alpha-blocker initiation to avoid paradoxical hypertension. 4