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GuideLines for Pharmacological Management of Chronic Stable Angina Pectoris

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Choice of antianginal agent
 
  • All patients should be offered short-acting nitrates either sublingually or via spray formulation. These drugs are used not only to treat an acute episode but also when an anginal attack is anticipated, e.g. prior to exercise.
  • Choice of first-line treatment for prophylaxis of anginal attacks, in general, is a selective beta blocker, if there are no contraindications. Alternative agents include long acting nitrates, calcium channel blockers, potassium channel openers or cytoprotective agents. Combination therapy can also be used.

 

Combination therapy
 
  • Indicated when single agent is ineffective
  • Provides balanced and complementary anti-anginal effect
  • Provides attenuation of side-effects
  • Offers enhanced patient compliance (in case of fixed-dose combinations)
  • Beta-blockers are frequently combined with nitrates or dihydropyridine calcium channel blockers (e.g. atenolol plus amlodipine)
  • Beta-blockers should be combined with verapamil and diltiazem with caution, because extreme bradycardia or heart block may occur

 

Drugs : Dosage guidelines
Class Example Initialting dose Usual maintenance dose
A) For prevention of MI and death
Lipid lowering drugs (e.g. statins) Simvastatin 5 - 10 mg once daily 5 - 40 mg once daily
Antiplatelet Aspirin 75 - 160 mg once daily 75 - 160 mg once daily
B) For symptom relief
Sublingual nitrates Nitroglycerin 0.3 mg-0.8 mg every five minutes till cessation of pain 0.3 mg-0.8 mg every five minutes till cessation of pain
Oral nitrates Isosorbide dinitrate 10-60 mg/day 30-120 mg/day
Isosorbide mononitrate 30-60 mg/day 60-120 mg/day
Transdermal nitrates Nitroglycerin 5 mg once daily 5-10 mg once daily
Beta-blockers Metoprolol 50-100 mg/day 100-200 mg/day
Atenolol 25-50 mg once daily 50-100 mg once daily
Calcium channel
blockers		 Diltiazem 90 mg/day 90-180 mg/day
Amlodipine 2.5-5 mg once daily 5-10 mg once daily
Cytoprotective drugs Trimetazidine 20 mg three times daily 20 mg three times daily
Potassium channel openers Nicorandil 5-10 mg twice daily 10-20 mg twice daily

 

Drugs: Side-effects and contraindications
Class Main side-effects Contraindications / Special precautions
Lipid lowering drugs (e.g. simvastatin) Intestinal irritation, liver enzyme elevation, skeletal muscle damage Hypersensitivity, active liver disease or unexplained persistent elevations of liver enzymes, pregnancy and lactation.
Antiplatelet agents (e.g. aspirin) Diarrhoea, gastro-intestinal bleeding, prolongation of bleeding time Hypersensitivity, history of gastro-intestinal bleeding, patients with bleeding disorders, nasal allergies, patients with chicken pox, influenza or flu symptoms, patients with gastric distress, ulcer or bleeding problems, pregnancy.
Nitrates (e.g. nitroglycerin, isosorbide dinitrate) Headache, dizziness, flushing, postural hypotension Hypersensitivity, shock, hypotensive collapse (systolic pressure below 100 mmHg), acute myocardial infarction with low filling pressures.
Beta-blockers (e.g. atenolol) Impotence, bradycardia, fatigue Hypersensitivity, bradycardia, conduction disturbances, diabetes, asthma, severe cardiac failure.
Calcium channel blockers (e.g. diltiazem, amlodipine) Headache, pedal edema In case of non-dihydropyridine calcium channel blockers (e.g. diltiazem) – Hypersensitivity, bradycardia, conduction disturbances, congestive heart failure, left ventricular dysfunction. In case of dihydropyridine calcium channel blockers (e.g. amlodipine)-Hypersensitivity.
Cytoprotective drugs (e.g. trimetazidine) Headache, gastric discomfort Hypersensitivity
Potassium channel openers (e.g. nicorandil) Headache,   dizziness, flushing, hypotension Hypersensitivity, shock, hypotension, left ventricular failure with low filling pressures.

 

Summary
 
  • Stable angina pectoris is a common and disabling disorder
  • With proper management, the symptoms can usually be controlled and the prognosis substantially improved
  • As a minimum, each patient should have a carefully taken history and physical examination, an assessment of risk factors and a resting electrocardiogram
  • Patients should be prescribed lipid lowering drugs if they have an abnormal lipid profile (LDL-cholesterol >100 mg/dl)
  • If there are no other contraindications, a selective beta-blocker is the drug of choice for providing symptom relief. Other effective alternatives include nitrates, calcium channel blockers, potassium channel openers and cytoprotective drugs


Treatment mnemonic: The 10 most important treatment elements of stable angina management

A = Aspirin and anti-anginal therapy
B = Beta-blocker and blood pressure
C = Cigarette smoking and cholesterol
D = Diet and diabetes
E = Education and exercise



Further Reading

  • Management of stable angina pectoris. Recommendations of the Task Force of the European Society of Cardiology. Eur Heart J 1997; 18: 394-413.
  • ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol 1999; 33: 2092-2190.
  • Drugs for angina. Update. January 1999.