What is the first line of treatment for stable angina (Angina Pectoris)?

From the Guidelines

Beta-blockers should be the first-line treatment for stable angina, as they have been shown to reduce morbidity and mortality in patients with chronic stable angina, particularly in those with prior myocardial infarction or heart failure. According to the most recent and highest quality study, 1, beta-blockers such as metoprolol, atenolol, or carvedilol reduce heart rate and blood pressure, decreasing myocardial oxygen demand.

Key Points to Consider:

• Beta-blockers are the preferred first-line treatment for stable angina, especially in patients with reduced left ventricular ejection fraction or post-infarct angina, or heart failure, as they have been shown to improve angina and reduce cardiovascular mortality and sudden death 1.
• Calcium channel blockers like amlodipine, diltiazem, or verapamil may be considered as an alternative or in addition to beta-blockers, as they cause vasodilation and reduce cardiac workload, but their use should be individualized based on comorbidities 1.
• Aspirin (81-325 mg daily) is recommended for long-term prevention to reduce thrombotic risk, as it has been shown to reduce vascular events in patients with acute and chronic ischemic heart disease 1.
• Treatment should be individualized based on comorbidities, with beta-blockers preferred in patients with prior myocardial infarction or heart failure, while calcium channel blockers may be better for those with bronchospastic disease.

Important Considerations:

• The choice of beta-blocker and calcium channel blocker should be based on the individual patient's characteristics, such as heart rate, blood pressure, and comorbidities.
• The use of beta-blockers and calcium channel blockers should be monitored closely, as they can have adverse effects, such as hypotension, bradycardia, and peripheral edema.
• Aspirin should be used with caution in patients with bleeding disorders or those taking anticoagulant medications.

Overall, the treatment of stable angina should prioritize the use of beta-blockers as the first-line treatment, with calcium channel blockers and aspirin used as adjunctive therapy or in specific clinical scenarios.

From the FDA Drug Label

The effectiveness of 5 to 10 mg/day of amlodipine in exercise-induced angina has been evaluated in 8 placebo-controlled, double-blind clinical trials of up to 6 weeks duration involving 1038 patients (684 amlodipine, 354 placebo) with chronic stable angina In 5 of the 8 studies, significant increases in exercise time (bicycle or treadmill) were seen with the 10 mg dose. Increases in symptom-limited exercise time averaged 12.8% (63 sec) for Amlodipine 10 mg, and averaged 7. 9% (38 sec) for Amlodipine 5 mg.

First line of medicine for stable angina:

• Amlodipine is used for the treatment of chronic stable angina.
• The recommended dose is 5 to 10 mg/day.
• Key benefits of amlodipine in stable angina include:
  • Increased exercise time
  • Decreased angina attack rate
  • Improved symptom-limited exercise time 2

From the Research

First Line of Medicine for Stable Angina

• The first line of medicine for stable angina is beta-blockers, as recommended by guidelines in the absence of contraindications 3, 4, 5, 6.
• Beta-blockers reduce heart rate and myocardial contractility, thus reducing myocardial oxygen consumption and ameliorating the frequency of anginal attacks 4.
• Calcium channel blockers are also considered a first-line treatment option, particularly for patients with certain comorbidities or those who cannot tolerate beta-blockers 3, 5, 6.
• Aspirin and statins are also recommended as disease-modifying agents for patients with stable angina 3, 5.

Treatment Considerations

• The choice of beta-blocker or calcium channel blocker should be individualized based on patient characteristics, such as heart rate, blood pressure, and comorbidities 4.
• Long-acting nitrates are considered third-line therapy due to the need for a nitrate-free interval to avoid developing tolerance 3.
• Coronary revascularization, such as coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty, may be required to control symptoms in certain patients 3.

Evidence Base

• Randomized controlled trials have shown that antianginal drugs, including beta-blockers and calcium channel blockers, are equally effective in relieving angina symptoms, but do not reduce mortality or the risk of myocardial infarction 5, 6, 7.
• A meta-analysis of randomized trials found no statistically significant evidence that beta-blockers impact on mortality in stable angina patients 7.