Selection of optimal therapy for chronic stable angina

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Patients with chronic stable angina (CSA) seek a medical opinion for relief of their symptoms and because of fear of having a heart attack. The underlying lesion responsible for CSA is often a severe narrowing of one or more coronary arteries. In addition, the coronary arteries of patients with CSA contain many more nonobstructive lesions, which progress at variable rates, and are prone to rupture and may manifest as acute coronary syndromes (myocardial infarction [MI], unstable angina [UA], or sudden ischemic death). Most patients with CSA can be managed with medical treatment. For angina relief, optimum doses of one of the antianginal drugs (ß blockers [BBs], long-acting organic nitrates, or calcium channel blockers [CCBs]) should be used. If the patient remains symptomatic, combination treatment of BBs plus nitrates or BBs plus dihydropyridine CCBs, or nondihydropyridine CCBs plus nitrates should be tried. Triple therapy has not been shown to be more effective than treatment with two agents. To reduce the incidence of MI, UA, and sudden ischemic death, treatment strategies should include smoking cessation, daily aspirin, daily exercise, and pharmacologic therapy for dyslipidemias, and for elevated blood pressure. Patients who remain symptomatic despite medical therapy and those not willing to take or unable to tolerate antianginal drugs should be considered for percutaneous or surgical coronary revascularization. Patients who do not respond to medical therapy and are not candidates for a revascularization procedure may be considered for additional treatment with trimetazidine or nicorandil (these drugs are not available in the United States or approved by the US Food and Drug Administration, but are available in some other countries). Ranolazine also looks promising but is not yet available for clinical use. As a last resort, enhanced external counterpulsation, spinal cord stimulation, sympathectomy, or direct transmyocardial revascularization should be considered for symptom relief.