Optimal Management of Stable Angina
All patients with stable angina should receive aspirin 75 mg daily, high-intensity statin therapy, and a beta-blocker as first-line anti-anginal therapy, with ACE inhibitors added for those with hypertension, diabetes, or prior MI. 1, 2
Immediate Pharmacological Interventions for Mortality Reduction
These medications must be initiated in all patients unless contraindicated, as they reduce cardiovascular death and MI:
Aspirin 75-325 mg daily should be started immediately in all patients with stable angina 1, 2. Clopidogrel 75 mg daily is reserved only for patients with absolute aspirin contraindications 1.
High-intensity statin therapy is mandatory regardless of baseline cholesterol levels, targeting LDL-C <70 mg/dL 1, 2, 3. This provides mortality benefit independent of lipid levels 1.
ACE inhibitor therapy is required for patients with hypertension, diabetes, heart failure, LV dysfunction, or prior MI 1, 2. Strong evidence supports ACE inhibitors even in lower-risk patients with stable CAD 1.
Beta-blockers are essential for all post-MI patients and provide mortality benefit 1, 2. Even without prior MI, beta-blockers reduce cardiovascular events and should be strongly considered 1.
First-Line Anti-Anginal Therapy
Beta-blockers are the preferred initial anti-anginal agent due to proven mortality benefits in post-MI patients and superior symptom control 1, 2, 4:
- Target doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 2
- Optimize the dose of a single beta-blocker before adding other agents 1, 2
- Diabetes is NOT a contraindication—diabetic patients benefit equally or more from beta-blockers 1, 2
- Critical warning: Never abruptly discontinue beta-blockers in patients with CAD, as this causes severe exacerbation of angina, MI, and ventricular arrhythmias 5. Taper over 1-2 weeks if discontinuation is necessary 5.
Short-acting sublingual nitroglycerin should be prescribed to all patients for immediate symptom relief and situational prophylaxis 1, 2.
Second-Line Anti-Anginal Therapy
If beta-blockers are contraindicated, not tolerated, or symptoms persist despite optimal dosing:
Long-acting calcium channel blockers (amlodipine 5-10 mg daily or diltiazem) are the preferred alternative 1, 2. Long-acting dihydropyridines (amlodipine) are often preferable due to sustained 24-hour effects 1.
Critical pitfall: NEVER use immediate-release or short-acting dihydropyridine calcium antagonists, as they increase adverse cardiac events 1, 2. Only long-acting formulations are safe 1.
Avoid combining non-dihydropyridine calcium antagonists (verapamil, diltiazem) with beta-blockers in patients with heart failure due to negative inotropic effects 2, 3.
Long-acting nitrates are third-line due to tolerance development requiring nitrate-free intervals 1, 4. They provide less consistent 24-hour coverage compared to calcium channel blockers 1.
Third-Line Add-On Therapy
When symptoms persist despite two optimally-dosed anti-anginal drugs:
Ranolazine 500-1000 mg twice daily can be added as third-line therapy, particularly for microvascular angina 2, 6. In the CARISA trial, ranolazine added to atenolol, amlodipine, or diltiazem significantly increased exercise duration and reduced angina frequency 6.
Switch drug combinations before attempting three-drug regimens, as three simultaneous anti-anginal drugs may provide less symptomatic protection than two drugs 2.
Mandatory Lifestyle Modifications
These interventions modify prognosis and must be implemented alongside pharmacotherapy:
- Smoking cessation is strongly advised and may require pharmacotherapy including nicotine replacement 1, 3
- Blood pressure control to <140/90 mmHg (or <130/80 mmHg with diabetes/CKD) is extremely important 1, 3
- Strict diabetic control and weight management are essential 1, 3
- Dietary modifications: saturated fats <7% of total calories, limited sodium, increased omega-3 fatty acids, fresh fruits and vegetables 3
- Regular exercise should be encouraged 7
Diagnostic Evaluation Requirements
Before finalizing treatment, confirm diagnosis and assess prognosis:
Exercise ECG is the initial non-invasive test of choice 1, 2. Interpret with attention to hemodynamic response, workload achieved, and ST-segment changes 1.
Stress echocardiography or myocardial perfusion scintigraphy are indicated when exercise ECG is not possible, not interpretable, or when diagnosis remains uncertain 1, 2. These tests demonstrate extent and localization of ischemia 1.
Echocardiography evaluates ventricular function and is particularly helpful in risk stratification 1, 2.
Special consideration for women: Classical angina symptoms are less reliable indicators of obstructive CAD in younger women, who have higher prevalence of coronary spasm and Syndrome X 1. Non-invasive imaging is particularly valuable for risk stratification in women 1.
Indications for Revascularization
Coronary angiography should be performed when symptoms are not satisfactorily controlled by medical therapy, with a view to revascularization 1, 2:
PCI is effective for anatomically suitable lesions in patients with angina not controlled by medical treatment 1, 2. However, PCI does not reduce mortality compared to medical therapy in stable angina 1.
CABG is highly effective for symptom relief AND reduces long-term mortality in specific subgroups: left main stenosis, proximal LAD stenosis, three-vessel disease (especially with LV dysfunction) 1, 2, 4.
Critical Pitfalls to Avoid
- Never use dipyridamole as an antiplatelet agent—it can enhance exercise-induced myocardial ischemia 1
- Never use chelation therapy—it has no proven benefit 1
- Poor medication adherence is a common cause of treatment failure and must be assessed at every visit 2
- An angina attack not responding to short-acting nitroglycerin should be regarded as possible MI 2
- Tolerance develops with long-acting nitrates unless nitrate-free intervals are maintained 1, 4
- Restenosis remains a problem with PCI despite advances in stenting technology 1