Overview
This table pragmatically presents the pharmacological classes used in stable angina, with examples, therapeutic-line positioning, contraindications, and clinical usage notes. The logic is simple: use first-line drugs for baseline symptom control, sublingual nitrates for rescue, and add second-line agents when control is insufficient or constrained by comorbidities.
Short-acting nitrates
We begin with short-acting nitrates, intended for immediate relief of an episode and anticipatory prophylaxis before exertion. Usual examples are sublingual nitroglycerin and sublingual isosorbide dinitrate. The major contraindication is combination with phosphodiesterase-5 inhibitors, which is absolute; add marked hypotension and obstructive hypertrophic cardiomyopathy. The table reinforces correct use: typical response in about five minutes, repeat every five minutes up to three total doses, and seek urgent medical care if there is no relief. For predictable exertion, administer five to ten minutes beforehand.
Long-acting nitrates
Long-acting nitrates—transdermal nitroglycerin, isosorbide dinitrate, or isosorbide mononitrate—are used as add-on/second-line therapy to reduce episodes. They share the same contraindications as short-acting nitrates and require a daily nitrate-free interval of 10–12 hours to minimize tolerance, with practical instructions on application and site rotation.
Beta-blockers
Among first-line agents, beta-blockers are the cornerstone: atenolol, bisoprolol, metoprolol, nebivolol, carvedilol, propranolol. The aim is to reduce heart rate and myocardial oxygen demand. They are contraindicated in marked bradycardia, second- or third-degree AV block without a pacemaker, uncontrolled asthma/active bronchospasm, and acute heart failure. A practical target is a resting HR of 55–60 bpm, with titration over 2–4 weeks and avoiding abrupt withdrawal.
Calcium channel blockers
Calcium channel blockers are divided into dihydropyridines—amlodipine, felodipine, sustained-release nicardipine—and non-dihydropyridines—verapamil and diltiazem. Both can be first line. Dihydropyridines are preferable in bradycardia or AV-conduction disease, used with caution in severe aortic stenosis and ideally as prolonged-release; immediate-release nifedipine should be avoided in stable angina. Non-dihydropyridines reduce HR and conduction; they are contraindicated in HFrEF, bradycardia, and AV block, and should not be combined with beta-blockers or ivabradine due to risk of conduction disturbances, especially in older patients.
Second line / add-ons
When control remains insufficient, use second-line/add-on therapy. Ivabradine is an option in sinus rhythm with HR ≥ 70 bpm; avoid in sick sinus syndrome and AV block ≥ 2 without a pacemaker, monitoring for bradycardia and atrial fibrillation. Ranolazine improves symptoms without lowering HR or BP; monitor QT and avoid with strong CYP3A4 inhibitors, in moderate–severe hepatic impairment, or if CrCl < 30 ml/min. Nicorandil is an alternative add-on, with attention to mucosal ulceration and hypotension, and should not be combined with PDE5 inhibitors.
