How to manage a patient with stable angina?

Management of Stable Angina

All patients with stable angina should receive aspirin 75-100 mg daily, high-intensity statin therapy, and beta-blockers as first-line anti-anginal therapy, with sublingual nitroglycerin for acute symptom relief. 1, 2, 3

Immediate Pharmacological Management

Medications to Prevent MI and Death (Mandatory for All Patients)

• Aspirin 75-100 mg once daily is mandatory for all patients without contraindications, as it reduces mortality and prevents thrombotic events 1, 2, 4
• If aspirin is absolutely contraindicated, clopidogrel should be substituted 1
• High-intensity statin therapy is required for all patients regardless of baseline cholesterol levels, targeting LDL-C <70 mg/dL when possible, due to proven mortality reduction 1, 4, 3
• ACE inhibitors are indicated for patients with hypertension, diabetes, heart failure, LV dysfunction, or prior MI with LV dysfunction 1, 2, 4

Anti-Anginal Therapy for Symptom Control

Step 1: First-Line Therapy

• Beta-blockers at optimal doses are the preferred initial anti-anginal agent due to mortality benefits in post-MI patients and proven symptom control 2, 4, 3
  • Bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 2
  • Diabetes is NOT a contraindication; diabetic patients benefit equally or more from beta-blockers 2
• Sublingual nitroglycerin or nitroglycerin spray should be prescribed for immediate relief of angina episodes and situational prophylaxis 1, 2, 3
  • Patients should rest briefly when angina occurs and use sublingual nitrate 1
  • Warn patients about potential hypotension (advise sitting initially) and headache 1
  • Critical pitfall: Angina persisting >10-20 minutes despite sublingual nitrate should prompt immediate medical evaluation for possible MI 1

Step 2: Second-Line Options

• If beta-blockers are contraindicated, not tolerated, or symptoms persist despite optimal dosing, add or substitute with long-acting calcium channel blockers (dihydropyridines like amlodipine, or non-dihydropyridines like diltiazem) 1, 2, 4
• Long-acting nitrates are an alternative second-line option, though calcium channel blockers are often preferred due to sustained 24-hour effects without need for nitrate-free intervals 1
• Critical pitfall: Avoid immediate-release or short-acting dihydropyridine calcium antagonists, as they increase adverse cardiac events 1, 2
• Critical pitfall: Do NOT combine verapamil or diltiazem with beta-blockers in patients with heart failure due to negative inotropic effects 2

Step 3: Third-Line Add-On Therapy

• If symptoms persist despite two anti-anginal drugs at optimal doses, consider ranolazine as add-on therapy, particularly for microvascular angina 2, 5
  • Ranolazine 500-1000 mg twice daily significantly reduces angina frequency and nitroglycerin use when added to maximal doses of other anti-anginals 5
• Nicorandil may be considered as add-on therapy, though safety data in heart failure is uncertain 2
• Critical pitfall: Using three anti-anginal drugs simultaneously may provide less symptomatic protection than two drugs 2
• Optimize one drug's dosing before adding another; switch drug combinations before attempting a three-drug regimen 2

Aggressive Risk Factor Modification (Mandatory)

• Smoking cessation must be strongly discouraged 1, 4
• Mediterranean diet with vegetables, fruit, fish, and poultry as mainstays 1, 4
• Aerobic exercise: 150-300 minutes per week of moderate intensity physical activity 3
• Weight reduction for overweight patients 1, 4
• Blood pressure control to target levels 1, 4
• Strict glycemic control in diabetic patients 1, 4
• Exercise-based cardiac rehabilitation significantly reduces cardiovascular mortality while improving risk factor control 3

When to Consider Coronary Revascularization

• Coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by medical therapy with two anti-anginal drugs at optimal doses, with a view to revascularization 2, 4
• PCI is effective for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present 2
• CABG reduces mortality in specific high-risk subgroups and is highly effective for symptom relief 2, 4:
  • Left main stenosis ≥50%
  • Three-vessel disease, especially with impaired LV function
  • Two-vessel disease with proximal LAD stenosis
• Patients with marked limitation of ordinary activity (Canadian Cardiovascular Society class III) despite maximal medical therapy should undergo coronary angiography 1

Follow-Up Strategy

• Follow-up evaluation every 4-6 months during the first year, then annually if stable 1, 4
• At each visit, assess five critical questions 1:
  1. Has physical activity level decreased?
  2. Have anginal symptoms increased in frequency or severity?
  3. How well is the patient tolerating therapy?
  4. How successful has risk factor modification been?
  5. Have new comorbid illnesses developed or worsened?
• Review patient response to medical therapies at 2-4 weeks after drug initiation 3
• Repeat stress testing is indicated when there is significant change in symptoms, new symptoms suggesting progression, or before revascularization 4
• More frequent visits are needed for patients who cannot reliably identify changes in their status or need more support with treatment 1

Common Pitfalls to Avoid

• Poor medication adherence is a common cause of treatment failure and should always be assessed 2
• Providing a written prescription for aspirin may help patients follow the recommendation 1
• Do not combine nicorandil with nitrates, as it lacks additional efficacy 2
• Do not combine ivabradine with non-dihydropyridine calcium channel blockers or strong CYP3A4 inhibitors 2
• Anginal symptoms may remain stable only because stressful activities have been eliminated—detailed history of activity level is critical 1