What is the recommended treatment for a patient with stable angina?

Treatment of Stable Angina

All patients with stable angina should receive aspirin, a statin, an ACE inhibitor, and a beta-blocker as foundational therapy to prevent myocardial infarction and death, with sublingual nitroglycerin for acute symptom relief. 1, 2

Medications That Reduce Mortality and Morbidity (Must Use)

These agents address the underlying disease process and improve cardiovascular outcomes:

• Aspirin 75-100 mg daily for all patients without contraindications (clopidogrel if aspirin is absolutely contraindicated) 1, 2, 3

• Statin therapy for all patients regardless of baseline cholesterol levels, as it reduces adverse ischemic events and mortality 1, 2, 3

• ACE inhibitor for all patients with stable angina, particularly beneficial in those with hypertension, heart failure, left ventricular dysfunction, prior MI, or diabetes 1, 2, 3

• Beta-blockers provide mortality benefit, especially in patients with prior MI (Level A evidence), and should be used in all patients unless contraindicated 1, 2, 4

  • Target heart rate: 55-60 beats per minute 4
  • Recommended doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 2
  • Beta-blockers are the only antianginal medication proven to improve long-term cardiovascular outcomes when given within 1 year after acute MI 4

Medications for Symptom Relief

Immediate Relief

• Sublingual nitroglycerin (0.3-0.6 mg) or nitroglycerin spray must be prescribed to all patients for acute anginal episodes 1, 2, 3, 4
  • Patients should call emergency services if symptoms are unimproved or worsening 5 minutes after one dose 4

First-Line Anti-Anginal Therapy

Beta-blockers are the preferred first-line agent for symptom control in most patients, particularly those with prior MI, heart failure, hypertension, or resting heart rate >60 bpm 2, 4

• Beta-blockers reduce myocardial oxygen demand by decreasing heart rate, contractility, and blood pressure 4
• Titrate to full dose before adding other agents 2, 4

Long-acting calcium channel blockers are equally effective alternatives when beta-blockers are contraindicated, not tolerated, or in specific scenarios 2, 3, 4:

• Preferred for vasospastic angina (Prinzmetal's angina), where they directly block coronary artery vasospasm 4
• Preferred for patients with COPD or peripheral arterial disease 4
• Amlodipine 5-10 mg daily reduces hospitalizations for angina and need for revascularization procedures 5

Critical contraindication: Beta-blockers are absolutely contraindicated in vasospastic angina as they can cause unopposed alpha-mediated vasoconstriction and worsen coronary spasm 4

Second-Line Anti-Anginal Therapy

If first-line therapy is inadequate:

• Add a dihydropyridine calcium channel blocker (e.g., amlodipine) to beta-blocker therapy 2, 3

  • Many patients require this combination for adequate symptom control 4

• Long-acting nitrates can be used as alternatives, but require a 10-14 hour nitrate-free interval daily to prevent tolerance 2, 3, 4

  • Nitrates have not been shown to reduce mortality in patients with CAD 1

• Ranolazine may be considered as add-on therapy if symptoms persist despite two anti-anginal drugs, particularly for microvascular angina 2

Third-Line Options

• Ivabradine, nicorandil, or trimetazidine are second-line agents added when first-line therapy is inadequate, contraindicated, or not tolerated 4
• No evidence exists that any antianginal medication improves long-term cardiovascular outcomes except beta-blockers post-MI 4

Risk Factor Modification (Essential)

• Smoking cessation is mandatory 2
• Strict diabetic control for all diabetic patients 2
• Blood pressure control targeting appropriate goals 2
• Weight management and regular exercise 2

When to Consider Revascularization

Coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by maximal therapeutic doses of two anti-anginal drugs, with consideration for revascularization 2, 3:

• PCI is effective for patients with angina not controlled by medical treatment when anatomically suitable lesions are present 2

• CABG is highly effective for symptom relief and reduces mortality in specific subgroups: left main stem stenosis, proximal LAD stenosis, or three-vessel disease with impaired LV function 2

Critical Pitfalls to Avoid

• Never abruptly discontinue beta-blockers—taper over 1-2 weeks to avoid severe exacerbation of angina, MI, or ventricular arrhythmias 4

• Avoid short-acting dihydropyridine calcium antagonists (e.g., immediate-release nifedipine) as they increase adverse cardiac events 1, 3

• Do not combine verapamil or diltiazem with beta-blockers in patients with heart failure due to negative inotropic effects 2

• Using three anti-anginal drugs simultaneously may provide less symptomatic protection than two drugs 2

• Do not use dipyridamole as it can enhance exercise-induced myocardial ischemia 3

• Chelation therapy is not recommended due to lack of evidence 1, 3

• Poor medication adherence is a common cause of treatment failure and should always be assessed 2

• When combining calcium channel blockers with beta-blockers, use a dihydropyridine (e.g., amlodipine) to avoid excessive bradycardia or heart block 4