The goals of
stable angina pectoris treatment are: (i) symptom relief and increase in angina-free walking time; and (ii) reduction of mortality and adverse outcome. Strategies used for plaque stabilisation resulting in a reduction in cardiovascular mortality and morbidity are: smoking cessation;
aspirin (
acetylsalicylic acid); blood pressure control;
lipid lowering agents when
low density lipoprotein cholesterol is elevated despite dietary
therapy; coronary bypass surgery in patients with left main stem disease or triple vessel coronary disease and diminished left ventricular function; and use of
estrogen in postmenopausal women. For symptom relief and to increase angina-free walking time, long acting
nitrates, beta-blockers,
calcium antagonists and
potassium channel openers can be used. Drugs from these 3 classes are all effective when used optimally and choice of initial
therapy should consider the presence of concomitant disease and underlying left ventricular function. However, none of the long acting
nitrates provide continuous prophylaxis because
nitrate tolerance develops during long term
therapy. In patients with uncomplicated
stable angina,
nitrates, beta-blockers and
calcium antagonists are all effective. Intermittent
nitrate therapy is not associated with tolerance, but
headache is a common adverse effect and the patient is unprotected at night and in the early hours of the morning. Concomitant treatment with a beta-blocker may be beneficial if the patient experiences withdrawal or early morning angina. For patients with
stable angina and
hypertension,
therapy with a beta-blocker or a
calcium antagonist rather than
nitrate is indicated. beta-Blockers are preferred in patients who have had a
myocardial infarction, or in those with a history of supraventricular
tachyarrhythmias. beta-Blockers may produce excessive slowing of the heart rate,
fatigue and
bronchospasm in susceptible patients.
Calcium antagonists are indicated as initial
therapy when beta-blockers are either not tolerated or contraindicated. beta-Blockers and nondihydropyridine
calcium antagonists should not be used in patients with sinus
bradycardia and those with greater than first degree atrioventricular (
AV) block because of the possibility of further slowing of heart rate and/or the development of high grade
AV block. When monotherapy with one class is ineffective or associated with adverse effects, the patient should be switched to another class rather than given an additional
drug. Optimal monotherapy is often as effective as combination
therapy. If maximum monotherapy is only partially effective, a combination
therapy which is not additive in terms of adverse effects should be chosen. Triple
therapy may be deleterious and no more effective than dual
therapy.