What is the optimal management plan for a patient with stable angina, including lifestyle modifications and pharmacological interventions?

Management of Stable Angina

All patients with stable angina should immediately receive aspirin 75-100 mg daily, high-intensity statin therapy targeting LDL <70 mg/dL, and beta-blockers as first-line antianginal therapy, combined with sublingual nitroglycerin for acute symptom relief and mandatory smoking cessation. 1

Dual Treatment Strategy

Management requires two distinct therapeutic approaches that cannot be achieved with the same medications 1:

• Prognostic therapy (preventing MI and death): aspirin, statins, ACE inhibitors 1
• Symptomatic therapy (reducing angina and improving quality of life): beta-blockers, calcium channel blockers, nitrates 1

This distinction is critical because antianginal drugs improve symptoms but have not been proven to reduce cardiovascular mortality or MI rates 2, 3.

Pharmacological Management

Disease-Modifying Agents (Prognostic Therapy)

Aspirin:

• Dose: 75-325 mg daily for all patients unless contraindicated 4, 1
• Dosages of 75-150 mg and 160-325 mg show similar reduction in vascular events 4
• Clopidogrel 75 mg daily is reserved only for aspirin-intolerant patients 4

Statin Therapy:

• Target LDL-C <70 mg/dL when possible 1
• Mandatory for all patients with stable angina regardless of baseline cholesterol 1

ACE Inhibitors:

• Indicated for patients with: coexisting ventricular dysfunction, hypertension, diabetes, prior MI with LV dysfunction, or other high-risk features 1
• Should be considered in all patients with high-risk features 4

Antianginal Therapy (Symptomatic Relief)

Beta-Blockers (First-Line):

• Use as initial therapy for chronic stable angina 1, 2
• Target doses: bisoprolol 10 mg once daily, metoprolol 200 mg once daily, or atenolol 100 mg daily 2
• Reduce cardiac events when used as secondary prevention in post-infarction patients 1
• All beta-blockers appear equally effective 5
• Absolute contraindication in vasospastic angina (causes unopposed alpha-mediated vasoconstriction) 2

Calcium Channel Blockers (Alternative First-Line):

• Equally effective as beta-blockers for symptom relief 2, 5
• Use when beta-blockers are contraindicated, cause unacceptable side effects, or fail to control symptoms 5
• Long-acting dihydropyridines can be combined with beta-blockers 4
• Gold standard first-line therapy for vasospastic angina: Verapamil 240-480 mg/day, Diltiazem 180-360 mg/day, or Nifedipine 60-120 mg/day 2

Long-Acting Nitrates (Third-Line):

• Considered third-line because nitrate-free interval is required to avoid tolerance 5
• All long-acting nitrates appear equally effective 5

Sublingual Nitroglycerin:

• Provide for acute symptomatic relief in all patients 1

Novel Antianginal Agents (Second-Line)

Ranolazine:

• FDA-approved for chronic stable angina as add-on therapy when symptoms persist despite maximum doses of other antianginals 6, 7
• Dose: 500 mg twice daily initially, titrate to 1000 mg twice daily 6
• Does not reduce heart rate or blood pressure 6
• Prolongs QTc interval (mean 6 msec at 1000 mg twice daily) 6
• In CARISA trial: reduced angina frequency from 3.3 to 2.1 attacks/week and nitroglycerin use from 3.1 to 1.8 doses/week when added to standard therapy 6

Lifestyle Modifications

Smoking Cessation:

• Mandatory for all patients—directly impacts mortality 1
• Use stepwise strategy: Ask, Advise, Assess, Assist, Arrange 4
• Nicotine patches are safe in patients with coronary artery disease 1

Blood Pressure Control:

• Target <140/90 mm Hg (or <130/80 mm Hg for patients with diabetes or chronic kidney disease) 4
• Initiate lifestyle modifications: weight control, increased physical activity, alcohol moderation, sodium restriction, diet high in fruits/vegetables/low-fat dairy 4

Exercise:

• Aerobic physical activity 150-300 minutes per week at moderate intensity or 75-150 minutes at vigorous intensity 1
• Exercise training improves exercise tolerance, symptoms, and psychological well-being 4

Diet:

• Mediterranean diet with emphasis on vegetables, fruit, fish, and poultry 1

Diabetes Management:

• Strict glycemic control required 4

Medication Optimization Algorithm

1. Optimize single-drug dosing before adding another agent 4
2. Switch drug combinations before attempting three-drug regimen 4
3. Tailor therapy to individual patient needs and monitor response 4

Revascularization Indications

Percutaneous Coronary Intervention (PCI):

• Indicated when symptoms not satisfactorily controlled by medical treatment and anatomically suitable lesions present 4, 1
• Does not reduce risk of death compared with medical therapy in stable angina 4
• Restenosis remains a problem despite advances in stenting 4

Coronary Artery Bypass Grafting (CABG):

• Highly effective for symptom relief 4
• Reduces mortality in specific subgroups: left main stem stenosis, proximal LAD stenosis, three-vessel disease (especially if LV function impaired) 4, 1
• 80% of patients remain angina-free 5 years post-surgery 5
• Initially more effective than medical therapy, but similar results after 5-10 years 5

Timing:

• Coronary arteriography should be undertaken when symptoms not satisfactorily controlled by medical means 4

Special Populations

Women:

• Classical angina symptoms less reliable in young and middle-aged women compared to men 4
• Higher prevalence of coronary artery spasm and Syndrome X 4
• Up to 40% may have microvascular angina rather than obstructive epicardial disease 1, 2

Elderly:

• Beta-blockers can be used safely 4

Common Pitfalls

• Do not use beta-blockers in vasospastic angina—they worsen coronary spasm 2
• Do not forget nitrate-free intervals—continuous use leads to tolerance 5
• Do not rely solely on symptom relief—prognostic therapy (aspirin, statins, ACE inhibitors) is mandatory even if asymptomatic 1
• Do not assume PCI reduces mortality—it is primarily for symptom control 4
• Do not overlook microvascular angina—explains why ischemia can persist after successful revascularization 1