From the Guidelines
Management of stable angina with a new decrease in left ventricular (LV) function should prioritize a comprehensive approach, including optimization of medical therapy and consideration of revascularization.
Key Considerations
- Optimization of medical therapy: According to 1, patients with stable angina pectoris should be treated with aspirin (75 mg/day) and statin therapy, and a beta-blocker should be used first line, unless contraindicated.
- Revascularization: As stated in 1, in patients with LVEF ≤35%, revascularization or medical therapy alone should be chosen after careful evaluation, preferably by the Heart Team.
- Anti-anginal drug treatment: As outlined in 1, a beta-blocker is recommended as the preferred first-line treatment to relieve angina, with alternatives such as ivabradine, nitrates, or amlodipine considered in patients who cannot tolerate a beta-blocker.
- Coronary revascularization: As recommended in 1, coronary revascularization is indicated when angina persists despite treatment with two antianginal drugs.
Specific Treatment Options
- Beta-blockers: Should be the preferred treatment in patients with reduced left ventricular ejection fraction (<40%) or with post-infarct angina, or heart failure, as stated in 1.
- Ivabradine: May be considered in patients in sinus rhythm who cannot tolerate a beta-blocker, to relieve angina, as suggested in 1.
- Nitrates: May be considered in patients unable to tolerate a beta-blocker, to relieve angina, as recommended in 1.
- Amlodipine: May be considered in patients unable to tolerate a beta-blocker, to relieve angina, as recommended in 1.
Important Considerations
- Individualized treatment: Anti-anginal drug treatment should be tailored to the needs of the individual patient, as stated in 1.
- Monitoring and adjustment: The dosing of one drug should be optimized before adding another one, and it is advisable to switch drug combinations before attempting a three drug regimen, as recommended in 1.
From the Research
Management of Stable Angina with Decreased Left Ventricular Function
The management of stable angina with a new decrease in left ventricular (LV) function involves a combination of medical therapy and potential revascularization procedures.
- Medical therapy aims to reduce morbidity and mortality, eliminate angina, and allow patients to return to normal activities with minimal adverse effects 2.
- The initial treatment for stable angina typically involves beta-blockers, unless contraindicated, in which case calcium antagonists may be used 2.
- For patients with left ventricular dysfunction, management should be medical, consisting of nitrates plus a beta-blocker or calcium antagonist, with the combination of these agents providing additional efficacy in severe ischemia 3.
- Angiotensin-converting enzyme (ACE) inhibitors may be used to slow the progression of left ventricular dysfunction and improve survival, although they should be used with caution as they may worsen angina in some patients 3.
Revascularization Procedures
Revascularization procedures, such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), may be considered for patients with stable angina who do not respond to medical therapy or have significant symptoms.
- CABG is often indicated for symptomatic patients with left-main disease, three-vessel disease, or two-vessel disease including proximal stenosis of the left anterior descending coronary artery, as it improves survival 2.
- PCI is an alternative to CABG for patients with normal left ventricular function and favorable angiographic features, and may be used to improve symptoms and prevent the need for subsequent revascularization 4.
- The choice of revascularization procedure depends on individual patient characteristics, including the presence of comorbid conditions and the severity of symptoms.
Additional Considerations
Additional considerations in the management of stable angina with decreased left ventricular function include:
- Patient education and long-term follow-up to assess clinical stability and reassess prognosis as warranted 2.
- The use of aspirin, unless contraindicated, to reduce the risk of adverse cardiovascular events 2.
- The treatment of risk factors, such as smoking, elevated low-density lipoprotein cholesterol level, diabetes, and hypertension, to reduce the risk of progression of coronary artery disease 2, 5.