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

Management of Stable Angina

Immediate First-Line Therapy

All patients with stable angina should receive aspirin 75 mg daily and statin therapy regardless of baseline cholesterol levels, as these medications reduce mortality and myocardial infarction risk. 1, 2

Essential Prognostic Medications (Start Immediately)

• Aspirin 75-150 mg daily unless contraindicated—improves survival 1, 2, 3
• Statin therapy for all patients with coronary disease—reduces mortality regardless of cholesterol levels 1, 2, 4
• ACE inhibitor if patient has hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes 1, 2, 4

First-Line Anti-Anginal Therapy

Beta-blockers are the preferred first-line anti-anginal agent due to mortality benefits in post-MI patients and proven symptom control. 1, 2, 4

Target doses:

• Bisoprolol 10 mg once daily 2, 3
• Metoprolol CR 200 mg once daily 2, 3
• Atenolol 100 mg daily 2, 3

Optimize the dose of one beta-blocker fully before adding another medication. 1, 2

Immediate Symptom Relief

• Prescribe sublingual nitroglycerin to all patients for acute symptom relief and situational prophylaxis 1, 2, 4
• Instruct patients to sit during first use to prevent hypotension 3
• Critical warning: If angina does not respond to nitroglycerin, this should be regarded as possible myocardial infarction requiring emergency care 2, 4

Second-Line Therapy (If Beta-Blockers Fail or Are Contraindicated)

Add or substitute with a dihydropyridine calcium channel blocker (amlodipine) or long-acting nitrate if beta-blockers are contraindicated, not tolerated, or symptoms persist despite optimal dosing. 1, 2, 4

Calcium Channel Blocker Options

• Amlodipine is preferred among dihydropyridines 2
• Diltiazem or verapamil can be used as alternatives 1
• Never use verapamil or diltiazem with beta-blockers in heart failure patients due to negative inotropic effects 2, 3

Long-Acting Nitrate Options

• Isosorbide mononitrate provides synergistic anti-ischemic effects when combined with beta-blockers by blocking reflex tachycardia 3
• Ensure proper dosing schedule with nitrate-free intervals to avoid tolerance 4

Third-Line Add-On Therapy

If symptoms persist despite two optimally dosed anti-anginal drugs, consider ranolazine as add-on therapy. 2, 5

Ranolazine Evidence

• FDA-approved for chronic stable angina as add-on therapy 5
• In the CARISA trial, ranolazine 750-1000 mg twice daily significantly increased exercise duration and time to angina (p<0.05) 5
• Reduced angina frequency from 3.3 to 2.1 attacks/week (p<0.001) 5
• Particularly effective for microvascular angina 2

Alternative Third-Line Agents

• Nicorandil can be considered, but safety data in heart failure is uncertain 2
• Ivabradine for patients with heart failure and LVEF <40% 2
• Do not combine ivabradine with non-dihydropyridine CCBs or strong CYP3A4 inhibitors 2

Risk Factor Modification (Concurrent with Pharmacotherapy)

Strict risk factor control is mandatory and may modify initial risk assessment. 1, 2

• Smoking cessation—strongly advised for all patients 1, 2
• Blood pressure control—extremely important 1, 2
• Strict diabetic control and weight management 1, 2
• Mediterranean diet and regular physical activity 3

When to Pursue Revascularization

Coronary arteriography with revascularization should be undertaken when symptoms are not satisfactorily controlled by medical therapy (two or more anti-anginal drugs at optimal doses). 1, 2, 4

PCI Indications

• Effective for patients with angina not controlled by medical treatment when anatomically suitable lesions are present 1, 2
• No evidence that PCI reduces death risk compared with medical therapy in stable angina 1

CABG Indications (Mortality Benefit)

• Left main stem stenosis 1, 2
• Proximal LAD stenosis 1, 2
• Three-vessel disease, especially with impaired LV function 1, 2

Critical Pitfalls to Avoid

• Never use immediate-release or short-acting dihydropyridine calcium antagonists (short-acting nifedipine) as they increase adverse cardiac events 2, 4, 3
• Using three anti-anginal drugs simultaneously may provide less symptomatic protection than two drugs—optimize dosing before adding third agent 1, 2, 4
• Switch drug combinations before attempting a three-drug regimen 1, 2
• Poor medication adherence is a common cause of treatment failure—always assess compliance 2, 4
• Do not combine verapamil/diltiazem with beta-blockers in heart failure due to negative inotropic effects 2, 3
• Do not combine nicorandil with nitrates—lacks additional efficacy 2

Diagnostic Confirmation and Risk Stratification

Exercise ECG is the initial non-invasive test of choice to confirm diagnosis and determine prognosis. 2, 3

• Alternative investigations (myocardial perfusion scintigraphy, stress echocardiography) are valuable when exercise ECG is not possible or interpretable 2, 3
• Careful interpretation of chest pain is particularly important in women, as classical symptoms may be less reliable indicators of coronary disease 2, 3
• Echocardiography helps evaluate ventricular function 2

Follow-Up Strategy

Patients should be evaluated every 4-6 months during the first year, then annually if stable. 1

Key Questions at Each Visit

• Has physical activity level decreased? 1
• Have anginal symptoms increased in frequency or severity? 1
• How well is the patient tolerating therapy? 1
• How successful has risk factor modification been? 1
• Have new comorbid illnesses developed? 1

Laboratory Monitoring

• Fasting glucose testing in follow-up visits 1
• Monitor general functional status and health-related quality of life 1