Chronic stable angina medical therapy
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Chronic stable angina medical therapy On the Web | ||
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Risk calculators and risk factors for Chronic stable angina medical therapy | ||
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [5]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan. M.B.B.S.
Overview
The goal of the management of chronic stable angina is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by myocardial infraction or development of heart failure. The mainstays of the treatment of chronic stable angina are patient education, lifestyle changes and medical therapy[1]. In patients with chronic stable angina, immediate symptomatic relief is achieved with short-acting sublingual nitrates and long term symptom relief is achieved with beta blockers as first line therapy, or calcium channel blockers and long-acting nitrates when beta blockers are contraindicated. Drugs that improve quality of life and associated with better prognosis include: low dose aspirin, beta-blockers and ACEIs.
Medical Therapy
Lifestyle modification and medical therapy are the first line treatment of patients with chronic stable angina.
The aims of the medical therapy is:
- Decrease premature cardiovascular death
- Decrease incidence of myocardial infarction and heart failure
- Increase survival
- Improve the quality of life
- Decrease the severity and frequency of angina
- Increase exercise tolerance
1- Patient Education
- Importance of life style changes
- Importance of compliance to medications.
2- Risk Factors Modification
Lipid profile:
- Daily physical activity
- Weight management
- Diet low in saturated fats, trans fat, cholesterol
- Pharmacotherapy with statins
Treatment of hypertension:
- Physical activity
- Moderate alcohol intake if any
- Diet low in sodium and rich in fruits, vegetables and low fat dairy products
- Pharmacotherapy with ACEIs and/or beta-blockers
Control of diabetes:
- Glycemic control
Physical activity:
- 30 to 60 minutes of moderate aerobic exercise at least five days a week
Weight management:
- Target BMI: between 18.5 and 24.9 Kg/m2
- Target waist circumference: less than 40 inches in males and less than 35 inches in females
Smoking cessation:
- Smoking cessation is strongly recommended
3- Prevention of Acute Coronary Syndromes
Aspirin:
- Aspirin (75-162 mg/day) minimize the risk of thrombosis superimposed on the chronic fixed obstruction.
- Aspirin should be used indefinetly unless contraindicated.
- If Aspirin is contraindicated, the second line treatment is clopidogrel.
Beta Blockers:
- Beta blockers reduce heart rate and myocardial oxygen demands, as well as the risk of fatal arrhythmias as a consequence of plaque rupture.
- Beta blockers have shown to prevent ischemia even with a single daily dose and their known long term prognostic benefit may also be generalized to other patients with ischemic heart disease.
- Beta blockers should be used at least three years following myocardial infaction or acute coronary syndromes.
- If left ventricular dysfunction is present, metoprolol, carvedilol or bisoprolol should be used.
ACE Inhibitors:
- Strong consideration should be given to the initiation of ACE inhibitors as potential disease modifying therapy.
- ACE inhibitors should be given to almost all patients with chronic stable angina especially in the presence of diabetes, hypertension or chronic kidney disease.
- Calcium channel blockers should be considered in patients who cannot tolerate beta blockers or nitrates or who respond inadequately to these drugs. However, CCBs are not preferred as initial therapy for the management of patients with stable exertional angina. Extended release nifedipine, second generation vasoselective calcium channel blockers, and extended-release verapamil or diltiazem are the calcium blockers of choice.
4- Symptomatic Relief
- All patients should also be given nitroglycerin and instructions about its therapeutic and prophylactic use.
Chronic Stable Angina: Initial Management
- For most patients, the initial therapy should consist of use of beta blockers, and if the response to beta blocker therapy is inadequate, nitrates may be added.
- If angina episodes occur more than 2-3 times in a week, a calcium channel blocker or a long acting nitrate may be added. Regardless of the frequency and severity of angina symptoms, adding a calcium antagonists and/or long lasting nitrates to the main treatment regimen may help to reduce blood pressure and subsequently improve ventricular function.
- In patients with special circumstances or concomitant diseases, specific medications, or combinations of medications are preferable.
- Consider adding a third agent if angina persists despite of two anti-anginal drugs.
- Evaluate fasting lipid profile and initiate proper lipid lowering drug therapy when necessary. Ideally start with HMG-CoA reductase inhibitor to reduce LDL cholesterol level below 100 mg/dl (less than 70 mg/dl in high-risk patients).
- Coronary angiography is indicated in patients with refractory symptoms or ischemia, wherein, administration of optimal medical therapy has failed to control the symptoms or ischemia. Coronary angiography is also indicated in high-risk patients with non invasive test results, and in those with special occupations or sedentary life styles that require a more aggressive approach.
Chronic Stable Angina: Individual Pharmacologic Agents
You can read in greater detail about each of the pharmacotherapy for chronic stable angina below by clicking on the link for that topic.
- Antiplatelet agents: Aspirin | Dipyridamole | Clopidogrel
- Antianginal agents: Nitrates | Beta Blockers | Calcium Channel Blockers | Potassium channel openers | Newer Anti-anginal Agents
Related Chapters
Sources
- Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology[2]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina[5]
References
- ↑ Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M; et al. (2012). "Strategies for Multivessel Revascularization in Patients with Diabetes". N Engl J Med. doi:10.1056/NEJMoa1211585. PMID 23121323.
- ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). %5bhttp://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf%5d "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology" Check
|url=value (help). Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367. - ↑ Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. [1] PMID: 10351980
- ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58.[2] PMID: 12515758
- ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[3] PMID: 17998462