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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.
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