What is the first‑line management for a patient with stable angina pectoris?

First-Line Management of Stable Angina Pectoris

All patients with stable angina must immediately start three mandatory medications: aspirin 75-100 mg daily, high-intensity statin therapy, and a beta-blocker as first-line antianginal therapy, combined with sublingual nitroglycerin for acute symptom relief. 1, 2

Immediate Foundational Therapy (Non-Negotiable)

Prognostic Medications (Prevent Death and MI)

• Aspirin 75-100 mg once daily is mandatory for all patients without contraindications, as it reduces cardiovascular mortality and morbidity 1, 2, 3
• High-intensity statin therapy regardless of baseline cholesterol levels, targeting LDL-C <70 mg/dL, with proven mortality reduction 1, 2
• ACE inhibitor if the patient has hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes 1, 4

First-Line Antianginal Therapy (Symptom Control)

• Beta-blockers are the preferred first-line antianginal agent due to mortality benefits in post-MI patients and proven efficacy in symptom control 1, 4, 2, 5
• Target doses: bisoprolol 10 mg once daily, metoprolol CR 200 mg once daily, or atenolol 100 mg daily 1, 4, 3
• Beta-blockers are NOT contraindicated in diabetes; diabetic patients benefit equally or more from their use 1
• Sublingual nitroglycerin for immediate relief of angina episodes and situational prophylaxis before known triggers 1, 4, 2

Critical Contraindications to Beta-Blockers

Beta-blockers should be avoided in: 4

• Severe bradycardia (heart rate <50 bpm)
• Second or third-degree heart block without pacemaker
• Decompensated heart failure
• Severe bronchospastic disease

Second-Line Therapy When Beta-Blockers Fail or Are Contraindicated

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

Calcium Channel Blockers

• Dihydropyridine CCB (e.g., amlodipine) if beta-blockers are contraindicated, not tolerated, or symptoms persist despite optimal dosing 1, 4
• AVOID short-acting nifedipine without a beta-blocker, as studies suggest increased adverse outcomes 4
• AVOID combining verapamil or diltiazem with beta-blockers in heart failure patients due to negative inotropic effects 1

Long-Acting Nitrates

• Isosorbide mononitrate provides synergistic anti-ischemic effects when combined with beta-blockers by blocking reflex tachycardia 1, 4
• Long-acting nitrates are considered third-line therapy and should be combined with beta-blockers, not used alone 4

Third-Line Add-On Therapy

If symptoms persist despite two antianginal drugs at optimal doses, consider ranolazine as add-on therapy, particularly for microvascular angina. 1, 5

• Ranolazine (inhibitor of late inward sodium current) can be used alone or in addition to nitrates or beta-blockers 1, 5
• Ranolazine appears particularly effective for patients with microvascular angina and endothelial dysfunction 5
• Alternative agents include ivabradine, nicorandil, and trimetazidine, though no direct comparisons have demonstrated superiority over first-choice agents 4

Essential Lifestyle Modifications (Parallel to Pharmacotherapy)

• Smoking cessation is the single most important modifiable risk factor directly impacting mortality 2
• Aerobic physical activity: 150-300 minutes per week at moderate intensity or 75-150 minutes at vigorous intensity 2
• Mediterranean diet emphasizing vegetables, fruit, fish, and poultry 2
• Blood pressure control: target <130/80 mmHg for patients with diabetes or renal disease, <130/85 mmHg for established coronary disease 2
• Weight reduction and strict diabetic control 6, 4

When to Consider Revascularization

Coronary angiography with possible revascularization should be considered when symptoms are not satisfactorily controlled by two antianginal drugs at optimal doses, or if high-risk features develop on noninvasive stress testing. 1, 4, 2

CABG Indications (Mortality Benefit)

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 Indications (Symptom Relief)

• PCI is effective for anatomically suitable lesions when symptoms are not satisfactorily controlled by medical treatment 6, 4, 2
• PCI provides superior symptom control and better exercise capacity compared to medical therapy alone, but does not provide substantial survival benefit 6

Common Pitfalls to Avoid

• Using three antianginal drugs simultaneously may provide less symptomatic protection than two drugs 1
• Poor medication adherence is a common cause of treatment failure and should always be assessed 1
• An attack of angina that does not respond to short-acting nitroglycerin should be regarded as a possible myocardial infarction 1
• Optimize one drug's dosing before adding another; switch drug combinations before attempting a three-drug regimen 1
• Up to 40% of patients with angina may have microvascular angina (coronary microvascular dysfunction) rather than obstructive epicardial disease, which explains why myocardial ischemia can persist after successful revascularization 4

Follow-Up Protocol

• Initial review at 2-4 weeks after drug initiation to assess response 2
• 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