What is the treatment for a patient with stable angina and a history of coronary artery disease?

Treatment of Stable Angina

All patients with stable angina require dual-track therapy: medications to prevent death and myocardial infarction (aspirin, beta-blockers, statins, ACE inhibitors), plus antianginal agents to control symptoms (beta-blockers, calcium channel blockers, or nitrates). 1

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

These medications improve survival and must be prescribed regardless of symptom control:

• Aspirin 75-150 mg daily is mandatory for all patients with coronary artery disease 1, 2

  • Doses of 75-150 mg daily provide equivalent cardiovascular protection to 160-325 mg daily with potentially fewer side effects 1
  • Clopidogrel 75 mg daily only if aspirin is absolutely contraindicated (not as first-line therapy) 1

• Beta-blockers are first-line therapy and reduce cardiac events and mortality 1, 2

  • Metoprolol 50-100 mg twice daily or atenolol 50-100 mg daily are preferred cardioselective options 2, 3
  • Particularly beneficial in patients with prior MI (Level A evidence) 1
  • Also effective in patients without prior MI (Level B evidence) 1
  • Diabetes is NOT a contraindication - diabetic patients benefit equally or more than non-diabetics 1, 2

• High-intensity statin therapy reduces cardiovascular events 1, 2

  • Atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily 2, 3
  • Target LDL cholesterol <70 mg/dL in patients with established coronary artery disease 2, 3
  • Add ezetimibe if LDL goals not achieved with maximum tolerated statin dose 2, 3

• ACE inhibitors provide vascular protection beyond blood pressure control 1

  • Ramipril 10 mg daily or perindopril 8 mg daily are evidence-based choices 2, 3
  • Particularly important in patients with diabetes, hypertension, or left ventricular dysfunction 1

Medications to Control Angina Symptoms

Immediate Relief

• Sublingual nitroglycerin 0.4 mg for acute angina episodes 1, 2
  • Instruct patients to take up to 3 doses at 5-minute intervals 2, 3
  • If pain persists after 3 doses, seek emergency care 2

First-Line Chronic Symptom Control

• Beta-blockers serve dual purposes - both preventing death and controlling symptoms 1, 2, 4
  • Optimize beta-blocker dose to maximum tolerated level before adding additional antianginal agents 2, 5
  • Target resting heart rate of 55-60 bpm if tolerated 1

Second-Line Options When Beta-Blockers Alone Are Insufficient

If beta-blockers are contraindicated or cause unacceptable side effects:

• Long-acting calcium channel blockers are the preferred alternative 1, 4
  • Amlodipine 5-10 mg daily (dihydropyridine) 6
  • Diltiazem or verapamil (non-dihydropyridines) for rate control 1
  • Never use short-acting dihydropyridines - they increase adverse cardiac events 1, 2

If beta-blockers alone are partially effective:

• Add long-acting calcium channel blocker (preferably amlodipine) for additive effect 1, 5
• The combination of beta-blocker plus dihydropyridine calcium channel blocker has the strongest evidence for additive antianginal effects 5

Alternative second-line agents:

• Long-acting nitrates (isosorbide mononitrate or dinitrate) 1
  • Require 10-14 hour nitrate-free interval to prevent tolerance 1, 5
  • Less preferred than calcium channel blockers due to tolerance issues 1
• Ranolazine 500-1000 mg twice daily can be added to beta-blockers or calcium channel blockers 7, 8
  • Particularly effective for microvascular angina and endothelial dysfunction 8
  • Does not affect heart rate or blood pressure 7

Critical Treatment Algorithm

1. Start all patients on aspirin + beta-blocker + high-intensity statin + ACE inhibitor 1, 2
2. Optimize beta-blocker dose first before adding other antianginal agents 2, 5
3. If symptoms persist despite optimal beta-blocker:
   • Add long-acting calcium channel blocker (amlodipine preferred) 1, 5
   • OR substitute calcium channel blocker if beta-blocker not tolerated 1
4. If two-drug combination fails:
   • Consider ranolazine as add-on therapy 7, 8
   • Do NOT routinely use three antianginal drugs - evidence shows three drugs may be less effective than two optimized drugs 5
5. Refer for coronary angiography and revascularization if symptoms remain uncontrolled despite maximal medical therapy 1, 2

Critical Pitfalls to Avoid

• Do NOT withhold beta-blockers in diabetic patients - diabetes is not a contraindication and these patients benefit significantly 1, 2
• Do NOT use dipyridamole as an antiplatelet agent - it can enhance exercise-induced myocardial ischemia in stable angina 1, 2
• Do NOT use short-acting dihydropyridine calcium antagonists (immediate-release nifedipine) - they increase adverse cardiac events 1, 2
• Do NOT abruptly discontinue beta-blockers - taper over 4 weeks if discontinuation necessary to prevent rebound angina 5
• Do NOT assume triple antianginal therapy is superior - two optimized drugs are often more effective than three 5
• Do NOT forget nitrate-free intervals - continuous nitrate exposure leads to tolerance within 24 hours 1, 5

Monitoring and Follow-Up

• Evaluate patients every 4-6 months during first year, then annually if stable 1
• Monitor blood pressure every 2-4 weeks until target <130/80 mmHg achieved 2, 3
• Check lipid profile at 4-6 weeks after initiating statin therapy 2, 3
• Monitor renal function and electrolytes periodically with ACE inhibitor therapy 2, 3
• Assess medication adherence at each visit - crucial for therapeutic success 2, 3
• Consider stress testing if significant change in clinical status occurs 1