Management of Stable Angina

Immediate Pharmacological Management

The American College of Cardiology recommends aspirin 75-100 mg once daily for all patients without contraindications, as it reduces mortality and prevents thrombotic events 1, 2, 4
If aspirin is absolutely contraindicated, clopidogrel should be substituted, as recommended by the American Heart Association 1
High-intensity statin therapy is required for all patients regardless of baseline cholesterol levels, targeting LDL-C <70 mg/dL when possible, due to proven mortality reduction, as stated by the American College of Cardiology 1, 3, 4
ACE inhibitors are indicated for patients with hypertension, diabetes, heart failure, LV dysfunction, or prior MI with LV dysfunction, according to the European Society of Cardiology 1, 2, 4
Beta-blockers at optimal doses are the preferred initial anti-anginal agent due to mortality benefits in post-MI patients and proven symptom control, as recommended by the American Heart Association 2, 4, 3
Sublingual nitroglycerin or nitroglycerin spray should be prescribed for immediate relief of angina episodes and situational prophylaxis, as stated by the European Heart Journal 1, 2, 3, 5

Smoking cessation must be strongly discouraged, as recommended by the European Heart Journal 5, 4
A Mediterranean diet with vegetables, fruit, fish, and poultry as mainstays is recommended, according to the European Heart Journal 5, 4
Aerobic exercise, such as 150-300 minutes per week of moderate intensity physical activity, is recommended, as stated by the American College of Sports Medicine 3
Weight reduction for overweight patients is recommended, according to the European Heart Journal 5, 4
Blood pressure control to target levels is recommended, as stated by the European Society of Cardiology 5, 4
Strict glycemic control in diabetic patients is recommended, according to the American Diabetes Association 5, 4

Coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by medical therapy with two anti-anginal drugs at optimal doses, with a view to revascularization, as recommended by the American College of Cardiology 2, 4
PCI is effective for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present, according to the American Heart Association 2
CABG reduces mortality in specific high-risk subgroups and is highly effective for symptom relief, as stated by the American College of Cardiology 2, 4

Follow-up evaluation every 4-6 months during the first year, then annually if stable, is recommended, according to the American College of Cardiology 7, 8, 9, 10, 4
At each visit, assess five critical questions, including physical activity level, anginal symptoms, medication tolerance, risk factor modification, and new comorbid illnesses, as recommended by the American College of Cardiology 7, 8, 9, 10
Review patient response to medical therapies at 2-4 weeks after drug initiation, as stated by the American Heart Association 3
Repeat stress testing is indicated when there is significant change in symptoms, new symptoms suggesting progression, or before revascularization, according to the American College of Cardiology 4

Poor medication adherence is a common cause of treatment failure and should always be assessed, as recommended by the American Heart Association 2
Providing a written prescription for aspirin may help patients follow the recommendation, according to the American College of Cardiology 10
Do not combine nicorandil with nitrates, as it lacks additional efficacy, as stated by the European Heart Journal 2
Do not combine ivabradine with non-dihydropyridine calcium channel blockers or strong CYP3A4 inhibitors, according to the American Heart Association 2