Chronic stable angina medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [5]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan. M.B.B.S.

Overview

The goal of pharmacotherapy in the management of chronic stable angina is to reduce the severity and frequency of symptoms and also to provide better prognosis. 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, calcium channel blockers and long-acting nitrates. Drugs that improve quality of life and associated with better prognosis include: low dose aspirin, beta-blockers and ACEIs.

Chronic stable angina- First line pharmacotherapy

• Aspirin to minimize the risk of thrombosis superimposed on the chronic fixed obstruction.

• Beta blockade to reduce heart rate and myocardial oxygen demands, as well as reduce 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.

• Strong consideration should be given to the initiation of ACE inhibitors as potential disease modifying therapy.

• 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.

• All patients should also be given nitroglycerin and instructions about its therapeutic and prophylactic use.

Chronic stable angina- Initial management

• For most patients, the initial therapy should consist of use of beta blockers, and if the response to beta blocker therapy is inadequate, nitrates may be added.

• 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.

• Evaluate fasting lipid profile and initiate proper lipid lowering drug therapy when necessary. Ideally start with HMG-CoA reductase inhibitor to reduce LDL cholesterol level below 100 mg/dl (less than 70 mg/dl in high-risk patients).

• 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.

• Antiplatelet agents: Aspirin | Dipyridamole | Clopidogrel

• Antianginal agents: Nitrates | Beta Blockers | Calcium Channel Blockers | Potassium channel openers | Newer Anti-anginal Agents

• ACEI/RAAS blockers

• Anti-lipid agents

• Guidelines for pharmacotherapy to improve prognosis and reduce symptoms

Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina