What is the recommended treatment plan for a patient with angina pectoris?

Management of Angina Pectoris

Immediate Foundational Therapy

All patients with stable angina must immediately start three mandatory medications: aspirin 75-100 mg daily, high-intensity statin therapy targeting LDL-C <70 mg/dL, and beta-blockers as first-line antianginal therapy, combined with sublingual nitroglycerin for acute symptom relief. 1, 2

This represents the dual-strategy approach required for angina management:

Prognostic Medications (Prevent MI and Death)

• Aspirin 75-100 mg once daily is non-negotiable for all patients without contraindications, reducing cardiovascular mortality and morbidity 1, 3, 2
• High-intensity statin therapy is mandatory regardless of baseline cholesterol levels, with proven mortality reduction 3, 2
• ACE inhibitors are indicated specifically for patients with hypertension, diabetes, heart failure, LV dysfunction, or prior MI 1, 3, 2

Symptomatic Medications (Relieve Angina)

• Beta-blockers are the preferred first-line antianginal agent due to mortality benefits in post-MI patients and proven symptom control 1, 3, 2
  • Metoprolol reduces heart rate, cardiac output, and myocardial oxygen requirements at any given level of effort 4
  • Oral dosages of 100-400 mg daily have been shown effective in controlled trials 4
• Sublingual nitroglycerin for immediate relief of angina episodes and situational prophylaxis before known triggers 3, 2

Escalation Algorithm for Persistent Symptoms

If angina persists despite optimal beta-blocker dosing:

1. Add calcium channel blockers (can substitute if beta-blockers are contraindicated or not tolerated) 2
2. Add long-acting nitrates for additional symptom control 1
3. Consider ranolazine as add-on therapy when symptoms persist despite beta-blockers and nitrates 5, 6

When symptoms remain uncontrolled despite two anti-anginal drugs at optimal doses, proceed to coronary arteriography with a view to revascularization. 2

Critical Lifestyle Modifications (Mandatory, Not Optional)

• Smoking cessation directly impacts mortality and is the single most important modifiable risk factor 1, 2
• Aerobic physical activity: 150-300 minutes per week at moderate intensity or 75-150 minutes at vigorous intensity 1, 3
• Mediterranean diet emphasizing vegetables, fruit, fish, and poultry 1
• Blood pressure control with target <130/80 mmHg for patients with diabetes or renal disease, and <130/85 mmHg for established coronary disease 7
• Strict glycemic control in diabetic patients with multifactorial intervention 7

Important Medication Considerations

Clopidogrel Alternative

• Clopidogrel 75 mg daily is indicated only for patients with aspirin intolerance or allergy 7
• The CAPRIE study showed clopidogrel was slightly more effective than aspirin 325 mg/day (ARR 0.51% per year), but this benefit appeared primarily in the peripheral vascular disease subgroup 7

NSAID Caution

Avoid COX-2 inhibitors without simultaneous aspirin therapy in stable angina patients. 7

• If NSAIDs are required, avoid ibuprofen as it prevents aspirin from irreversibly acetylating platelet COX-1 7
• Diclofenac does not interfere with aspirin's antiplatelet effects and may be used in combination 7

Revascularization Indications

CABG reduces mortality in specific high-risk subgroups: 2

• Left main stenosis ≥50%
• Three-vessel disease, especially with impaired LV function
• Two-vessel disease with proximal LAD stenosis

PCI is effective for anatomically suitable lesions when symptoms are not satisfactorily controlled by medical treatment. 1, 2

Follow-Up Protocol

• Initial review at 2-4 weeks after drug initiation to assess response 3
• Routine follow-up every 4-6 months to assess angina frequency, nitroglycerin use, functional capacity, medication adherence, and physical examination 2
• Repeat stress testing is indicated when there is significant change in symptoms, new symptoms suggesting progression, or before revascularization 2

Special Diagnostic Consideration

Up to 40% of patients may have microvascular angina (coronary microvascular dysfunction) rather than obstructive epicardial disease, explaining why ischemia can persist after successful revascularization. 1 This is particularly important in women, who have higher prevalence of coronary artery spasm and Syndrome X. 1

Initial Diagnostic Testing

• Exercise ECG is the initial non-invasive test of choice to confirm diagnosis and determine prognosis, assessing hemodynamic response, workload achieved, clinical features, and ST-segment response 1, 2
• Resting 12-lead ECG and fasting lipid panel with glucose are recommended in all patients 2