Management of Angina Pectoris

Introduction to Angina Management

The American College of Cardiology recommends that all patients with stable angina should immediately receive aspirin 75-100 mg daily, statin therapy, and beta-blockers as first-line therapy, combined with sublingual nitroglycerin for acute symptom relief and aggressive risk factor modification including mandatory smoking cessation 1, 2

The European Society of Cardiology states that management of angina fundamentally requires two distinct therapeutic strategies that cannot be achieved with the same medications: prognostic therapy (preventing MI and death) and symptomatic therapy (reducing angina and improving quality of life) 1
Prognostic therapy includes aspirin, statins, and ACE inhibitors, which do not alleviate symptoms but prevent MI and death, according to the American Heart Association 3, 1

Up to 40% of patients may have microvascular angina (coronary microvascular dysfunction) rather than obstructive epicardial disease, explaining why ischemia can persist after successful revascularization, as noted by the European Heart Journal 1

The American College of Cardiology distinguishes between chronic stable angina and unstable angina, with unstable angina having a high to moderate short-term risk for acute coronary events, according to the Annals of Internal Medicine 3, 4

The European Heart Journal notes that classical angina symptoms are less reliable indicators of coronary disease in young and middle-aged women compared to men, compounded by higher prevalence of coronary artery spasm and Syndrome X in women 5, 6

The European Society of Cardiology recommends exercise ECG as the initial non-invasive test of choice to confirm diagnosis and determine prognosis, with attention to hemodynamic response, workload achieved, clinical features and symptoms, and ST-segment response 5, 6, 1

The American Heart Association recommends aspirin 75-100 mg daily as mandatory for all patients to reduce cardiovascular mortality and morbidity, with dosages of 75-150 mg daily and 160-325 mg daily showing similar reduction in vascular events 3, 4, 6, 1, 2
The European Society of Cardiology states that beta-blockers should be used first-line as initial therapy for chronic stable angina, reducing cardiac events when used as secondary prevention in post-infarction patients and reducing mortality and morbidity among patients with hypertension 3, 4, 5, 6, 1
The American College of Cardiology recommends statin therapy to achieve LDL-C <70 mg/dL when possible, with ACE inhibitors indicated for patients with coexisting ventricular dysfunction, hypertension, diabetes, prior MI with LV dysfunction, or other high-risk features 7, 6, 1, 2

The American Heart Association strongly emphasizes smoking cessation as it directly impacts mortality, with nicotine patches safely used to help patients with coronary artery disease stop smoking 4, 7, 2
The European Society of Cardiology recommends aerobic physical activity of 150-300 minutes per week at moderate intensity or 75-150 minutes at vigorous intensity, with a Mediterranean diet and emphasis on vegetables, fruit, fish, and poultry 2

The European Heart Journal notes that coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by medical means, with a view to revascularization, and that Percutaneous Coronary Intervention (PCI) is effective for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present 5, 6, 1
The American College of Cardiology states that Coronary Artery Bypass Grafting (CABG) is highly effective for symptom relief and reduces mortality risk in specific subgroups, including left main stem stenosis, proximal LAD stenosis, and three-vessel disease, especially if LV function is impaired 5, 6, 1