Successful management of the patient with
chronic stable angina requires correct stratification by assessing the risk of future coronary events. Patients at low risk for such events have a relatively good prognosis; revascularization procedures (balloon angioplasty or surgery) offer no benefit over medical management. Such patients should be offered medical
therapy as their first option. The goals in management of chronic
stable angina are (1) treatment of other conditions that may worsen angina; (2) treatment with
aspirin and modification of risk factors for
coronary artery disease (CAD) to improve outcome; and (3) effective relief of anginal symptoms. Most patients with
stable angina will have CAD. It is well established that treatment with
aspirin and modification of risk factors for CAD are beneficial in reducing cardiovascular mortality and morbidity. Blood pressure reduction, lowering of blood
cholesterol level, and smoking cessation are interventions of proven value and appear to correct defects (at least partially) in the endothelial function of the coronary blood vessels. Other interventions that are helpful are
estrogen replacement treatment in postmenopausal women, and low-dose
aspirin therapy-which is recommended for all patients who can tolerate it. For controlling symptoms and improving angina-free walking time,
nitrates, beta blockers, and
calcium channel antagonists are efficacious as first-line monotherapy for
chronic stable angina in this group of patients.
Nitrates may be of special use in patients with impaired left ventricular function, overt
congestive heart failure, intermittent coronary vasoconstriction, or
coronary artery spasm. In patients with concomitant
hypertension or
supraventricular tachycardia, beta blockers are helpful.
Calcium channel antagonists may be useful in patients with
chronic obstructive pulmonary disease,
peripheral vascular disease, or
hypertension. When optimal monotherapy with a given class of
drug fails to control symptoms, alternative monotherapy with a different class of agent should be tried before combination
therapy. Combination
therapy with 2 or 3 agents is not always superior to optimal monotherapy. Patients who fail to respond to adequate medical
therapy should be considered for a revascularization procedure.