Frequently asked questions — Treatment of stable angina
1) What are the pillars of treatment?
Three pillars: lifestyle, including diet, exercise, smoking cessation and weight control; event prevention, including antiplatelet/anticoagulant therapy according to context, lipid control and comorbidity management; and symptom control with antianginal drugs.
2) What is “first-line” treatment for symptoms?
Beta-blocker or calcium-channel blocker. Always provide a sublingual nitrate for relief of attacks. The choice between beta-blocker and calcium-channel blocker depends on heart rate (HR), blood pressure (BP) and comorbidities.
3) When should a dihydropyridine calcium-channel blocker be preferred over a beta-blocker?
In baseline bradycardia or when vasospasm is suspected. Examples include amlodipine/felodipine, ideally prolonged-release formulations. Avoid immediate-release nifedipine.
4) When should non-dihydropyridine calcium-channel blockers, verapamil/diltiazem, be avoided?
Avoid in heart failure with reduced ejection fraction, bradycardia and AV block. Do not combine with beta-blockers or ivabradine, due to the risk of bradycardia/heart block.
5) How should sublingual nitrates be used during an attack and for anticipatory prophylaxis?
Sublingual nitroglycerin 0.3–0.6 mg: onset in ~5 minutes; repeat every 5 minutes up to 3 doses, 15 minutes. If there is no relief, seek medical assistance. For predictable exertion, administer 5–10 minutes before.
6) Long-acting nitrates: what precautions are needed?
Use as an add-on/second-line option to reduce episodes. Ensure a daily nitrate-free interval of 10–12 hours to prevent tolerance. Absolute contraindication with phosphodiesterase-5 inhibitors, sildenafil/vardenafil < 24 h; tadalafil < 48 h.
7) When should ivabradine be considered?
In sinus rhythm with HR ≥ 70 bpm when HR reduction is desired with little BP reduction; 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 should ranolazine be used?
Useful when the aim is to preserve HR and BP, as it does not significantly reduce either. Monitor QT and CYP3A4 interactions; avoid if creatinine clearance is < 30 mL/min or in moderate/severe hepatic impairment.
9) What is the role of nicorandil?
An add-on option in refractory cases; it combines nitric oxide donor activity with potassium-channel opening. Watch for hypotension and mucosal ulceration. Do not combine with phosphodiesterase-5 inhibitors.
10) What about trimetazidine?
A metabolic option in selected cases with persistent symptoms; it does not alter HR/BP. Use with caution in older patients; monitor for rare extrapyramidal symptoms.
11) Which combinations are useful and which should be avoided?
Useful: DHP + beta-blocker, mitigating DHP-induced reflex tachycardia; combination with nitrates/nicorandil or ranolazine. Avoid: verapamil/diltiazem + beta-blocker or + ivabradine, because of bradycardia/AV block.
12) How and when should therapy be reassessed?
Reassess after 2–4 weeks: symptoms, HR, BP, adverse effects and adherence. If control is insufficient or there is intolerance, optimise the dose, add/switch to a second-line antianginal and reassess. Consider stratification and revascularisation when symptoms persist or high-risk features are present.
13) Does control of lipids, blood pressure and comorbidities influence symptoms?
Yes. Statins, with or without ezetimibe/PCSK9 inhibitors, reduce events and may reduce angina. Treating hypertension and comorbidities, including diabetes, heart failure and kidney disease, improves symptoms and prognosis.
14) Is there clear superiority between antianginal classes?
No. Evidence does not show consistent superiority between classes for symptom relief; therefore, choice should be individualised, according to HR, BP, comorbidities and preferences.
