Frequently asked questions — Treatment of stable angina
1) What are the pillars of treatment?
Three pillars: lifestyle (diet, exercise, smoking cessation, weight), event prevention (antiplatelet/anticoagulation as per context, lipid control and comorbidities), and symptom control with antianginal drugs.
2) What is “first-line” for symptoms?
Beta-blocker or calcium-channel blocker (CCB). Always provide sublingual nitrate for relief of attacks. The choice between BB and CCB depends on heart rate (HR), blood pressure (BP), and comorbidities.
3) When to prefer a dihydropyridine CCB over a beta-blocker?
In baseline bradycardia or when vasospasm is suspected. Examples: amlodipine/felodipine (ideally sustained-release). Avoid immediate-release nifedipine.
4) When to avoid non-dihydropyridine CCBs (verapamil/diltiazem)?
Avoid in heart failure with reduced ejection fraction, bradycardia, and AV block. Do not combine with beta-blockers or ivabradine (risk of bradycardia/block).
5) How to use sublingual nitrates in an attack and for anticipatory prophylaxis?
SL nitroglycerin 0.3–0.6 mg: onset in ~5 minutes; repeat every 5 minutes up to 3 doses (15 minutes). If no relief, seek medical care. For predictable exertion, administer 5–10 minutes beforehand.
6) Long-acting nitrates: what precautions?
Use as an add-on/second line to reduce episodes. Ensure a daily nitrate-free interval of 10–12 hours to avoid tolerance. Absolute contraindication with phosphodiesterase-5 inhibitors (sildenafil/vardenafil < 24 h; tadalafil < 48 h).
7) When to consider ivabradine?
In sinus rhythm with HR ≥ 70 bpm when HR reduction is desired with minimal BP drop; as an alternative/add-on if tachycardia persists despite a tolerated beta-blocker. Avoid in sick sinus syndrome and AV block ≥ 2 without a pacemaker.
8) When to use ranolazine?
Useful when HR and BP sparing is desired (does not meaningfully lower them). Monitor QT and CYP3A4 interactions; avoid if creatinine clearance < 30 mL/min or in moderate/severe hepatic impairment.
9) What is the role of nicorandil?
An add-on option in refractory cases; combines nitric-oxide donation and potassium-channel opening. Beware of hypotension and mucosal ulceration. Do not combine with phosphodiesterase-5 inhibitors.
10) And trimetazidine?
A metabolic option in selected cases with persistent symptoms; does not change HR/BP. Use cautiously in older adults; monitor for rare extrapyramidal symptoms.
11) Which combinations are useful and which should be avoided?
Useful: DHP + beta-blocker (mitigates reflex tachycardia); combinations with nitrates/nicorandil or ranolazine. Avoid: verapamil/diltiazem + beta-blocker or + ivabradine (bradycardia/AV block).
12) How and when to reassess therapy?
Reassess at 2–4 weeks: symptoms, HR, BP, adverse effects, and adherence. If control is insufficient or intolerance occurs, optimise dose, add/switch a second-line antianginal, and reassess. Consider risk stratification and revascularisation when symptoms persist or risk is high.
13) Do lipid, blood pressure, and comorbidity control influence symptoms?
Yes. Statins (with/without ezetimibe/PCSK9 inhibitors) reduce events and may lessen angina. Treating hypertension and comorbidities (diabetes, heart failure, kidney disease) improves symptoms and prognosis.
14) Is there clear superiority among antianginal classes?
No. Evidence does not show consistent superiority between classes for symptom relief; therefore, choice should be individualised (HR, BP, comorbidities, preferences).
