Antiplatelet Therapy for Stable Angina
Patients with stable angina should be treated with aspirin 75 mg daily as the cornerstone of secondary prevention, continued indefinitely unless contraindications exist. 1, 2
Primary Antiplatelet Recommendation
- Aspirin 75-100 mg daily is the first-line antiplatelet agent for all patients with stable angina and should be initiated promptly and continued long-term 1, 2
- The dose range of 75-150 mg daily provides equivalent cardiovascular protection to higher doses (160-325 mg) while minimizing bleeding risk 1
- After an initial 4-year treatment period, aspirin should be continued indefinitely at 75 mg daily 1
Alternative When Aspirin is Contraindicated
- Clopidogrel 75 mg daily is reasonable antiplatelet therapy when aspirin cannot be tolerated due to hypersensitivity or major gastrointestinal contraindications (principally recent significant bleeding from peptic ulcer or gastritis) 1
- Clopidogrel has demonstrated efficacy at least similar to aspirin for secondary prevention in patients with established vascular disease 1
Critical Contraindications to Aspirin
Aspirin should be avoided in patients with: 1
- Active bleeding or hemophilia
- Aspirin allergy or intolerance (primarily manifested as asthma with nasal polyps)
- Active peptic ulcer disease
- Severe untreated hypertension
- Active retinal bleeding
Important Drug Interaction
- Patients should avoid ibuprofen or take it at least 30 minutes after immediate-release aspirin or at least 8 hours before aspirin to prevent diminution of aspirin's protective effects 1
- Alternative NSAIDs should be considered when possible 1
What NOT to Use
- Dipyridamole should NOT be used as an antiplatelet agent in stable angina as usual oral doses can enhance exercise-induced myocardial ischemia 1
Dual Antiplatelet Therapy is NOT Indicated
Unlike acute coronary syndromes or post-PCI patients, stable angina does not require dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) 1. The evidence supporting dual antiplatelet therapy applies specifically to:
- Unstable angina/NSTEMI during the acute phase 1
- Post-percutaneous coronary intervention (limited duration) 1
- Acute coronary syndrome settings 1
For stable angina without recent intervention, single antiplatelet therapy with aspirin alone is the evidence-based standard 1, 2.
Integration with Comprehensive Medical Therapy
Antiplatelet therapy should be combined with: 1, 2
- Statin therapy (regardless of baseline cholesterol, for mortality benefit)
- Beta-blockers (especially if prior MI or heart failure)
- ACE inhibitors (if hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes)
This combination addresses both symptom control and mortality reduction, which are the dual goals of stable angina management 1.