Chronic stable angina medical therapy
Chronic stable angina Microchapters
Alternative Therapies for Refractory Angina
Guidelines for Asymptomatic Patients
Chronic stable angina medical therapy On the Web
The goal of the management of chronic stable angina is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by myocardial infarctionn or development of heart failure. The mainstays of the treatment of chronic stable angina are patient education, lifestyle changes and medical therapy. In patients with chronic stable angina, immediate symptomatic relief is achieved with short-acting sublingual nitrates and long term symptom relief is achieved with beta blockers as first line therapy, or calcium channel blockers and long-acting nitrates when beta blockers are contraindicated. Drugs that improve the quality of life and are associated with a better prognosis include: low dose aspirin, beta-blockers and ACEIs.
- Lifestyle modification and medical therapy are the first line treatment of patients with chronic stable angina.
Goals of the Medical Therapy
- To decrease premature cardiovascular death:
- To improve the quality of life:
- By decreasing the severity and frequency of angina
- By increasing exercise tolerance
Shown below is an image illustrating the different components of the management plan of a patient with chronic stable angina:
- Importance of life style changes
- Importance of compliance to medications
Risk Factors Modification
- Daily physical activity
- Weight management
- Diet low in saturated fats, trans fat, cholesterol
- Pharmacotherapy with lipid lowering drug therapy ideally HMG-CoA reductase inhibitor to reduce LDL cholesterol level below 100 mg/dl (less than 70 mg/dl in high-risk patients).
Treatment of Hypertension
- Physical activity
- Moderate alcohol intake if any
- Diet low in sodium and rich in fruits, vegetables and low fat dairy products
- Pharmacotherapy with ACEIs and/or beta-blockers
Control of Diabetes
- Glycemic control
- 30 to 60 minutes of moderate aerobic exercise at least five days a week.
- Target BMI: between 18.5 and 24.9 Kg/m2
- Target waist circumference: less than 40 inches in males and less than 35 inches in females
- Strong recommendation to stop smoking
Angina pectoris is considered an absolute contraindication to the use of the following medications:
Prevention of Acute Coronary Syndrome
- Aspirin (75-162 mg/day) minimizes the risk of thrombosis superimposed on the chronic fixed obstruction.
- Aspirin should be used indefinitely unless contraindicated.
- If Aspirin is contraindicated, the second line treatment is clopidogrel.
- Beta blockers reduces heart rate and myocardial oxygen demands, as well as the risk of fatal arrhythmias as a consequence of plaque rupture.
- Beta blockers have shown to prevent ischemia even with a single daily dose and their known long term prognostic benefit may also be generalized to other patients with ischemic heart disease.
- Beta blockers should be used at least three years following myocardial infaction or acute coronary syndrome.
- If left ventricular dysfunction is present, metoprolol, carvedilol or bisoprolol should be used.
- Strong consideration should be given to the initiation of ACE inhibitors as potential disease modifying therapy.
- ACE inhibitors should be given to almost all patients with chronic stable angina especially in the presence of diabetes, hypertension or chronic kidney disease.
- Calcium channel blockers should be considered in patients who cannot tolerate beta blockers or nitrates or who respond inadequately to these drugs. However, CCBs are not preferred as initial therapy for the management of patients with stable exertional angina. Extended release nifedipine, second generation vasoselective calcium channel blockers, and extended-release verapamil or diltiazem are the calcium blockers of choice.
- The first line therapy consists of the use of beta blockers, and if the response to beta blocker therapy is inadequate, nitrates may be added.
- For immediate symptomatic relief, sublingal or spray nitroglycerine should be used.
- If angina episodes occur more than 2-3 times in a week, a calcium channel blocker or a long acting nitrate may be added. Regardless of the frequency and severity of angina symptoms, adding a calcium antagonists and/or long lasting nitrates to the main treatment regimen may help to reduce blood pressure and subsequently improve ventricular function.
- In patients with special circumstances or concomitant diseases, specific medications, or combinations of medications are preferable.
- Consider adding a third agent if angina persists despite of two anti-anginal drugs.
- Coronary angiography is indicated in patients with refractory symptoms or ischemia, wherein, administration of optimal medical therapy has failed to control the symptoms or ischemia. Coronary angiography is also indicated in high-risk patients with non invasive test results, and in those with special occupations or sedentary life styles that require a more aggressive approach.
Chronic Stable Angina: Individual Pharmacologic Agents
You can read in greater detail about each of the pharmacotherapy for chronic stable angina below by clicking on the link for that topic:
- Antianginal agents: Nitrates | Beta Blockers | Calcium Channel Blockers | Potassium Channel Openers | Newer Anti-anginal Agents
- Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012.