- Stable angina is typically provoked by exertion and relieved by rest or nitrate therapy
- Risk stratification should be done to define prognosis, guide management and select appropriate patients for revascularisation
- Risk stratification is based on
- gender
- left ventricular function
- provocation of myocardial ischaemia with stress testing
- severity of coronary artery disease seen on angiography
- left ventricular function
- Echocardiography to see left ventricular function, and regional wall motion abnormalities
- In patients with stable coronary artery disease, left ventricular ejection fraction is the strongest predictor of long-term survival.
- The 12-year survival of medically treated patients with
- ejection fractions > 50% = 73%
- ejection fractions 35% and 49% = 54%
- ejection fractions <35= 21%
- The 12-year survival of medically treated patients with
- provocation of myocardial ischaemia with stress testing
- Stress testing on a treadmill
- Exercise Stress Echo or Pharmacological stress echocardiography
- if resting ECGs are abnormal or unable to be interpreted (because of left bundle branch block, paced rhythm).
- Myocardial perfusion scintigraphy
- uninterpretable ECGs or inability to exercise
- severity of coronary artery disease
- CT coronary arteries
- CT angiography
- reserved for those who are
- not overweight
- without excessive coronary calcium (Agatston score <400)
- sinus rhythm with resting heart rates of 65 beats/minute or less, with or without medication
- reserved for those who are
- invasive coronary angiography
- The aims of medical therapy are to control symptoms, improve quality of life and prevent cardiovascular events.
- Beta blockers and calcium channel antagonists remain first-line options for treatment.
- Short-acting nitrates can be used for symptoms
| Drug | Indications | Mechanism | Adverse effects | Precautions |
| Nitrates (short- and long-acting) | Relief of acute or anticipated pain (short-acting) Prevention of angina (long-acting) | Systemic and coronary vasodilation | Headache Hypotension Syncope Reflex tachycardia | Avoid sildenafil and similar drugs Tolerance with long-acting nitrates |
| Beta blockers | First-line therapy for exertional angina and after myocardial infarction | Reduce blood pressure, heart rate and contractility Prolongs diastolic filling time | Fatigue Altered glucose Bradycardia Heart block Impotence Bronchospasm Peripheral vasoconstriction Hypotension Insomnia or nightmares | Avoid with verapamil because of risk of bradycardia Avoid in asthma, 2nd and 3rd degree heart block and acute heart failure |
| Dihydropyridine calcium channel antagonists (e.g. amlodipine, felodipine, nifedipine) | Alternative, or in addition, to a beta blocker Coronary spasm | Systemic and coronary vasodilator | Hypotension Peripheral oedema Headache Palpitations Flushing | Avoid short-acting nifedipine because of reflex tachycardia and increased mortality in ischaemia |
| Non-dihydropyridine calcium channel antagonists (e.g. verapamil, diltiazem) | Alternative, or in addition, to a beta blocker | Arteriolar vasodilator Centrally acting drugs reduce heart rate, blood pressure, contractility, and prolong diastole | Negative inotropic effect Bradycardia Heart block Constipation Hypotension Headache | Avoid verapamil in heart failure and in combination with a beta blocker |
| Nicorandil | Angina | Systemic and coronary vasodilator | Headache Dizziness Nausea Hypotension Gastrointestinal ulceration | Avoid sildenafil and similar drugs Metformin may reduce efficacy |
| Ivabradine | Angina Chronic heart failure | Reduces heart rate | Visual disturbances Headache Dizziness Bradycardia Atrial fibrillation Heart block | Caution with drugs that induce or inhibit cytochrome P450 3A4 Avoid in renal or hepatic failure |
| Perhexiline | Refractory angina | Favours anaerobic metabolism in active myocytes | Headache Dizziness Nausea, vomiting Visual change Peripheral neuropathy | Narrow therapeutic range Need to monitor adverse effects and drug concentrations |