Management of Angina Pectoris

Diagnosis

The European Society of Cardiology recommends that careful interpretation of chest pain is particularly important in women, as classical symptoms may be less reliable indicators of coronary disease compared to men 1
Exercise ECG is the initial non-invasive test of choice to confirm diagnosis and determine prognosis, according to the European Heart Journal 1
Alternative investigations, such as myocardial perfusion scintigraphy and stress echocardiography, are valuable for demonstrating extent and localization of ischemia 2

The European Heart Journal suggests that treatment aims to improve prognosis by preventing myocardial infarction and death, and to minimize or abolish symptoms 3
Risk factor modification through lifestyle changes, such as smoking cessation, adopting a "Mediterranean" diet, regular physical activity, weight reduction, and strict diabetic control, should be implemented alongside pharmacological intervention, as recommended by the European Heart Journal [4] [5]

The European Heart Journal recommends that aspirin 75 mg daily, statin therapy, and beta-blockers should be used as first-line therapy for angina pectoris 6
Beta-blockers, such as bisoprolol, metoprolol, or atenolol, are effective as first-line anti-anginal therapy, with target doses of 10 mg once daily, 200 mg once daily, or 100 mg daily, respectively [6] [7]
ACE inhibitors are recommended for patients with coexisting hypertension, heart failure, LV dysfunction, prior MI with LV dysfunction, or diabetes, according to the European Heart Journal 6
Short-acting nitrates, such as sublingual nitroglycerin, are effective for immediate symptom relief and situational prophylaxis, but patients should be instructed to sit during first use to prevent hypotension [6] [3]

The European Heart Journal suggests that Percutaneous Coronary Intervention (PCI) is effective for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present 4
Coronary Artery Bypass Grafting (CABG) is highly effective for symptom relief and may reduce mortality risk in specific subgroups, such as left main stem stenosis, proximal LAD stenosis, or three-vessel disease with impaired LV function 4

Pharmacological therapy for chronic stable angina has two fundamentally different objectives: prognostic therapy (preventing MI and death) and symptomatic therapy (reducing angina and improving quality of life), which cannot be achieved with the same medications, according to the European Society of Cardiology 8, 9
Prognostic therapy (preventing MI and death): aspirin, statins, and ACE inhibitors do not alleviate symptoms, as recommended by the American Heart Association 8, 9
Symptomatic therapy (reducing angina and improving quality of life): antianginal drugs do not improve survival, as stated by the European Society of Cardiology 8, 10, 11

Long-acting nitrates are considered third-line therapy and can be combined synergistically with beta-blockers to block reflex tachycardia, as recommended by the American College of Cardiology 9
Combinations of medications should have additive or synergistic effects, according to the European Society of Cardiology 8, 9
Nitrates combined with beta-blockers provide synergistic anti-ischemic effects by blocking reflex tachycardia, as stated by the American Heart Association 9

For patients with contraindications or inadequate response to first-line therapy, second-choice medications include ivabradine, nicorandil, ranolazine, and trimetazidine, as recommended by the European Society of Cardiology 10, 11
No direct comparisons have demonstrated superiority of first-choice over second-choice agents, according to the American College of Cardiology 10, 11
Up to 40% of patients with angina may have microvascular angina (coronary microvascular dysfunction) rather than obstructive epicardial disease, which explains why myocardial ischemia can persist after successful revascularization, as stated by the European Society of Cardiology 8, 9

The American College of Cardiology recommends adding a long-acting nitrate, such as isosorbide mononitrate, to beta-blocker therapy if symptoms persist, as it provides synergistic anti-ischemic effects by blocking reflex tachycardia when combined with beta-blockers 12
Calcium channel blockers, such as amlodipine or diltiazem, can be considered as second-line agents if beta-blockers are contraindicated or poorly tolerated, according to the American College of Cardiology 12
The American Heart Association suggests avoiding the use of short-acting nifedipine without a beta-blocker, as studies suggest increased adverse outcomes 13

Beta-blockers are contraindicated in patients with severe bradycardia, second or third-degree heart block without pacemaker, decompensated heart failure, and severe bronchospastic disease, as stated by the American College of Cardiology 14

The American College of Cardiology recommends sublingual nitroglycerin for immediate symptom relief during acute anginal episodes 12

Coronary angiography with possible revascularization should be considered if high-risk features develop on noninvasive stress testing, according to the American College of Cardiology 14
The American College of Cardiology suggests that the patient should undergo risk stratification with exercise ECG or stress imaging to guide further management decisions 12, 14