What is the recommended management plan for a patient with stable angina?

Management of Stable Angina

All patients with stable angina should receive aspirin 75-325 mg daily, high-intensity statin therapy targeting LDL-C <70 mg/dL, and a beta-blocker as first-line anti-anginal therapy, with ACE inhibitors added for those with hypertension, diabetes, prior MI, or left ventricular dysfunction. 1, 2

Disease-Modifying Pharmacotherapy (Reduces MI and Death)

These medications must be prescribed to all patients unless contraindicated:

• Aspirin 75-325 mg daily (or clopidogrel 75 mg daily if aspirin is absolutely contraindicated) 1, 2
• High-intensity statin therapy with target LDL-C <70 mg/dL when achievable; if baseline LDL is very high, aim for >50% reduction in LDL-C 1, 2
• ACE inhibitor for all patients with coexisting ventricular dysfunction (EF <0.40), hypertension, diabetes, or prior MI 1, 2
• Beta-blocker particularly in patients with prior MI (Class I, Level A evidence) or without prior MI (Class I, Level B evidence) 1, 2

Symptomatic Anti-Anginal Therapy

First-Line: Beta-Blockers

• Beta-blockers are the preferred initial anti-anginal agent due to proven mortality benefit in post-MI patients and effective symptom control 1, 2
• All beta-blockers appear equally effective for angina relief 3
• Optimize dosing of a single agent before adding additional therapy 1

Second-Line: When Beta-Blockers Fail or Are Contraindicated

• Long-acting calcium channel blockers (either dihydropyridines like amlodipine or non-dihydropyridines like diltiazem) can be substituted if beta-blockers cause unacceptable side effects or are contraindicated 1
• Long-acting nitrates are an alternative, though calcium channel blockers are often preferred due to sustained 24-hour effects without need for nitrate-free intervals 1
• Avoid short-acting dihydropyridine calcium antagonists as they increase adverse cardiac events 1

Combination Therapy

• Add long-acting calcium channel blocker or long-acting nitrate to beta-blocker when beta-blocker monotherapy at optimal dose fails to control symptoms 1
• Switch drug combinations before attempting three-drug regimens 1

Acute Symptom Relief

• Sublingual nitroglycerin or nitroglycerin spray for immediate relief of angina 1
• Patients should rest briefly when angina occurs and use sublingual nitrate 1
• Warn patients about potential hypotension (advise sitting initially) and headache 1
• Prophylactic nitrate use before predictable exertion-induced angina is appropriate 1
• Seek immediate medical attention if angina persists >10-20 minutes despite rest and sublingual nitrate 1

Newer Agents for Refractory Angina

• Ranolazine 500-1000 mg twice daily can be added when symptoms persist despite two anti-anginal drugs at optimal doses 4
• In the CARISA trial, ranolazine significantly increased exercise duration and time to angina versus placebo when added to standard therapy (atenolol, amlodipine, or diltiazem) 4
• Ranolazine reduced angina frequency from 3.3 to 2.1 attacks/week and nitroglycerin use from 3.1 to 1.8 doses/week at the 1000 mg twice-daily dose 4

Aggressive Risk Factor Modification

Mandatory Lifestyle Interventions

• Smoking cessation is essential and strongly discouraged; consider referral to smoking cessation programs 1, 2
• Mediterranean diet emphasizing vegetables, fruit, fish, and poultry 1, 2
• Regular aerobic exercise 30-60 minutes daily or at least 3-4 times weekly (walking, jogging, cycling); assess risk with exercise test to guide prescription 1, 2
• Weight reduction targeting BMI 18.5-24.9 kg/m²; initial goal is 10% reduction from baseline 1
• Waist circumference <40 inches (102 cm) in men and <35 inches (89 cm) in women 1

Metabolic Control

• Strict glycemic control with HbA1c monitoring for diabetic patients 1, 2
• Blood pressure control is extremely important 1, 2
• Lipid management: If triglycerides ≥150 mg/dL or HDL <40 mg/dL, emphasize weight management and physical activity 1

Coronary Revascularization Indications

When to Refer for Coronary Angiography

• Symptoms not satisfactorily controlled by two anti-anginal drugs at optimal doses 1, 2
• Severe (CCS Class III) chronic stable angina despite medical management in suitable candidates 1

CABG Provides Mortality Benefit In:

• Left main stenosis ≥50% 1, 2
• Three-vessel disease, especially with impaired LV function 1, 2
• Two-vessel disease with proximal LAD stenosis 1, 2
• CABG is initially more effective than medical therapy but yields similar results after 5-10 years; 80% remain angina-free at 5 years 3

PCI Indications

• Anatomically suitable lesions in patients with angina not controlled by medical treatment 1, 2
• No evidence that PCI reduces death risk versus medical therapy in stable angina 1
• For diabetic patients with multivessel disease, CABG with internal mammary arteries is preferred over PCI 1

Follow-Up Monitoring

Visit Frequency

• Every 4-6 months during the first year of therapy 1, 2
• Annually after the first year if patient is stable and reliable in reporting symptom changes 1
• More frequent visits for patients unable to reliably identify status changes or needing additional support 1

Assessment at Each Visit

• Angina frequency and severity: Has physical activity level decreased? Have symptoms worsened? 1, 2
• Nitroglycerin use frequency 2
• Medication adherence and tolerance, especially aspirin 1
• Risk factor modification success: smoking status, weight, exercise, diet 1
• Physical examination: weight, blood pressure, pulse, jugular venous pressure, carotid bruits, pulmonary exam, cardiac exam 1

Repeat Stress Testing Indications

• Significant change in symptoms or new symptoms suggesting disease progression 2
• Before revascularization procedures 2

Therapies to Avoid

• Dipyridamole should not be used 1
• Chelation therapy should not be used 1
• Short-acting dihydropyridine calcium antagonists increase adverse cardiac events 1