Treatment of Angina: Core Medications
All three drugs listed—aspirin, beta-blockers, and nitroglycerin—are essential components of angina treatment, so none should be excluded. However, if this is a test question asking which drug does NOT provide prognostic benefit (mortality/morbidity reduction), the answer would be nitroglycerin, as it only relieves symptoms without reducing death or myocardial infarction rates.
Medications That Reduce Mortality and Morbidity
Aspirin is a Class I recommendation (Level of Evidence A) for all angina patients without contraindications, as it prevents myocardial infarction and death by inhibiting platelet aggregation 1. The European Society of Cardiology recommends 75 mg daily in all patients with stable angina unless there are specific contraindications such as active gastrointestinal bleeding, aspirin allergy, or previous intolerance 1.
Beta-blockers carry a Class I recommendation (Level of Evidence A) for patients post-myocardial infarction or with heart failure, and Level of Evidence B for patients without prior MI 1. They reduce mortality and morbidity by:
- Decreasing myocardial oxygen demand through heart rate and contractility reduction 1
- Lowering blood pressure 1
- Improving perfusion of ischemic areas by prolonging diastole 1
The American College of Physicians confirms beta-blockers prevent MI and death in patients with previous MI (Level A evidence) and in those without prior MI (Level B evidence) 1.
Medications That Only Relieve Symptoms
Nitroglycerin and other nitrates provide symptom relief but do NOT reduce mortality or prevent myocardial infarction 1. The European Society of Cardiology explicitly states that "studies of long acting nitrate treatment after myocardial infarction have failed to show prognostic benefit" 1.
Nitroglycerin's Role in Treatment
Short-acting sublingual nitroglycerin is recommended (Level of Evidence B) for immediate relief of acute anginal attacks and for situational prophylaxis before activities that may trigger angina 1, 2. The mechanism involves:
- Venodilatation and reduced diastolic filling pressure 1
- Promotion of subendocardial perfusion 1
- Coronary vasodilation and antagonism of coronary vasospasm 1
Long-acting nitrates reduce anginal frequency and severity but require a nitrate-free interval of 10-14 hours daily to prevent tolerance 1, 3. Continuous nitrate therapy leads to tolerance that blunts the response even to short-acting nitroglycerin 1.
Critical Distinction for Clinical Practice
The key distinction is between prognostic medications (aspirin, beta-blockers, statins, ACE inhibitors) that reduce death and MI versus symptomatic medications (nitrates, calcium channel blockers) that only improve quality of life through symptom control 1, 2.
All angina patients should receive aspirin and beta-blockers unless contraindicated, as these provide mortality benefit 1. Nitroglycerin should be added for symptom management but does not substitute for prognostic therapy 1, 2.
Common Pitfall to Avoid
Do not rely solely on nitrates for angina management—they must be combined with prognostic medications 1, 2. A systematic review covering 50 years of angina treatment found no evidence that any anti-anginal drug is superior to another for symptom control, but only certain drugs (aspirin, beta-blockers, statins, ACE inhibitors) reduce mortality 4.
If a patient's angina does not respond to sublingual nitroglycerin, this should be regarded as a possible myocardial infarction requiring immediate medical attention 1, 5.