Chronic stable angina treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor(s)-In-Chief: ; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan. M.B.B.S.

Overview
Treatment of chronic stable angina aims at minimizing symptoms, reducing recurrent ischemia, improving the quality of life and improving prognosis by preventing MI and death. Treatment options include lifestyle modification, pharmacotherapy and revascularization that help in slowing the disease progression, preserving the endothelial function and preventing thrombosis.

Patients with single-vessel CAD may be started on initial pharmacologic therapy and if non-responsive or symptomatic despite on therapy, PCI may be a preferred alternative.

Patients with double-vessel CAD and with normal LV function may be started on initial medical management and in non-responders, PCI may be considered. However, the decision of PCI versus CABG depends on the coronary anatomy, LV function and the need for complete revascularization.

Patients with triple-vessel CAD or left main disease or reduced left ventricular function, CABG is the mainstay of management. However, in cases of mild symptoms or preserved LVEF in patients with triple-vessel disease, initial pharmacologic therapy or PCI may be tried.

Precipitating factors

 * While chronic stable angina may be due to underlying atherosclerosis, other factors may either precipitate or exacerbate angina.


 * Identification and management of these conditions may reduce the frequency and intensity of anginal episodes. These conditions include:
 * Anemia,
 * Uncontrolled hypertension,
 * Thyroid disorders (thyrotoxicosis),
 * Heart rhythm abnormalities (tachyarrhythmias),
 * Decompensated congestive heart failure and
 * Concomitant valvular heart disease.

Risk factor modification

 * Initiation of intensive modification of risk factors is an urgent and essential part of the main therapy in chronic stable angina.


 * Initiate risk factor modification, promote regular physical exercise (all patients should be encouraged to obtain 30 to 60 minutes/day of regular aerobic activity), low fat diet, and lifestyle modification.

Smoking Cessation | Weight Management | Physical Activity | Lipid Management | BP Control | Diabetes Control | ACC/AHA Guidelines for Cardiovascular Risk Factor Reduction
 * You can read in greater detail about each of the risk factor modification topics below.

The treatment essentials
Alphabet of chronic stable angina management: elements listed below are the most important components of stable angina management.
 * A: Aspirin use
 * A: Anti anginal therapy
 * B: Beta blocker use
 * B: Blood pressure control
 * C: Cholesterol lowering therapy
 * C: Cigarette smoking cessation
 * D: Diabetes Mellitus control
 * D: Diet
 * E: Exercise
 * E: Education

Pharmacotherapy

 * The role of pharmacotherapy in the management of chronic stable angina is to reduce the severity and frequency of symptoms and to provide a bettered overall prognosis.


 * In patients with chronic stable angina, immediate symptomatic relief is achieved with short-acting sublingual nitrates and long term relief of symptoms is achieved with beta blockers, calcium channel blockers and long-acting nitrates.


 * Drugs that improve quality of life and are associated with better prognosis include: low dose aspirin, ACEIs, beta-blockers.


 * You can read in greater detail about each of the pharmacotherapies for chronic stable angina below by clicking on the link for that topic
 * Overview


 * Antiplatelet agents: Aspirin | Dipyridamole | Clopidogrel


 * Antianginal agents: Nitrates | Beta Blockers | Calcium Channel Blockers | Potassium channel openers | Newer Anti-anginal Agents


 * ACEI/RAAS blockers


 * Anti-lipid agents


 * Guidelines for pharmacotherapy to improve prognosis and reduce symptoms

Revascularization

 * Revascularization is only used for select patients specially those who have uncontrolled symptoms with optimal medical therapy.


 * This can be achieved with either percutaneous coronary intervention (PCI) with stent placement or coronary artery bypass surgery.
 * In general, PCI is reserved for single or some cases of two vessel disease, and
 * CABG is reserved for patients with two or three vessel disease or left main disease.


 * With the availability of drug-eluting stents, PCI is increasingly being performed for many lesions including more complex ones.

PCI | CABG | PCI vs CABG | ACC/AHA Guidelines for Revascularization
 * You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic.

Alternative therapies for refractory angina
You can read in greater detail about each of the alternative therapies for refractory angina below by clicking on the link for that topic. Transmyocardial Revascularization | Spinal Cord Stimulation | Enhanced External Counter Pulsation (EECP) | ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Vote on and Suggest Revisions to the Current Guidelines

 * The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * [Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology


 * The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina


 * The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina


 * The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina