Which of the following statements about the treatment of angina pectoris are correct?

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Treatment of Angina Pectoris: Statement Analysis

Statement (a) is partially correct but oversimplified, (c) is correct for unstable angina specifically, while (b), (d), and (e) are incorrect.

Statement-by-Statement Analysis

Statement (a): Beta-blockers are the treatment of choice

This is TRUE for symptomatic therapy but incomplete. Beta-blockers are recommended as first-line antianginal agents for symptom control 1, 2, 3. However, they are not "the" sole treatment of choice because:

  • All patients require triple foundational therapy: aspirin 75-100 mg daily, high-intensity statin therapy, and beta-blockers 3
  • Beta-blockers are one component of first-line therapy alongside calcium channel blockers and short-acting nitrates 1
  • No antianginal drug class has demonstrated superiority over others in direct comparisons 1
  • Meta-analyses show all antianginal drugs have similar efficacy in reducing symptoms 1

Target beta-blocker doses: bisoprolol 10 mg once daily, metoprolol 200 mg once daily, or atenolol 100 mg daily 2, 4

Statement (b): ACE inhibitors are the treatment of choice when the patient also has hypertension

This is FALSE. ACE inhibitors are indicated for specific comorbidities but are NOT antianginal agents:

  • ACE inhibitors do not relieve angina symptoms 2
  • They are indicated for patients with coexisting ventricular dysfunction, hypertension, diabetes, or post-MI with LV dysfunction 1, 2
  • The actual treatment of choice for angina with hypertension is beta-blockers or calcium channel blockers 1, 4
  • ACE inhibitors provide prognostic benefit (preventing MI and death) but not symptomatic relief 2

Statement (c): Heparin is indicated for the treatment of unstable angina

This is TRUE. While the provided evidence focuses on stable angina, this statement addresses unstable angina, which represents a different clinical entity requiring anticoagulation as part of acute coronary syndrome management.

Statement (d): Revascularization is indicated only in patients under 60 years of age

This is FALSE. Age is not a criterion for revascularization:

  • Revascularization indications are based on anatomy and symptom control, not age 1
  • CABG is indicated for: left main stenosis ≥50%, three-vessel disease (especially with impaired LV function), and proximal LAD stenosis 1, 3
  • PCI is indicated when symptoms are not controlled by medical treatment and anatomically suitable lesions are present 1, 4
  • Coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by medical means 1, 4

Statement (e): Treatment of dyslipoproteinemia is not valuable when the patient has angina

This is FALSE and dangerous. Statin therapy is mandatory:

  • High-intensity statin therapy is non-negotiable regardless of baseline cholesterol levels 3
  • Statins provide proven mortality reduction 3
  • All patients with stable angina should receive statin therapy 1, 2, 4
  • Statin therapy is one of the three foundational medications that all angina patients must receive 3

Critical Treatment Algorithm

Phase 1 - Mandatory for ALL patients:

  • Aspirin 75-100 mg daily 3, 4
  • High-intensity statin therapy 3
  • Sublingual nitroglycerin for acute relief 2, 3

Phase 2 - First-line antianginal therapy:

  • Beta-blockers (preferred) 1, 2, 3
  • If contraindicated: calcium channel blockers or long-acting nitrates 1, 4

Phase 3 - Add ACE inhibitors if:

  • Hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes 1, 2

Phase 4 - If symptoms persist:

  • Add second antianginal agent (long-acting nitrate or calcium channel blocker) 4
  • Consider ranolazine as third-line add-on 4

Phase 5 - Revascularization when:

  • Symptoms not controlled with two antianginal drugs 4
  • High-risk anatomy (left main, three-vessel disease, proximal LAD) 1, 3

Common Pitfalls

  • Never use three antianginal drugs simultaneously - less effective than two drugs 4
  • Avoid immediate-release nifedipine - increases adverse cardiac events 4
  • Do not combine verapamil/diltiazem with beta-blockers in heart failure - negative inotropic effects 4

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Angina Pectoris

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Management of Angina Pectoris

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Management of Stable Angina

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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