• Any contributory cause is treated when possible, e.g. anaemia, arrhythmia.
• Life style is changed so as to reduce the number of attacks. Weight reduction can be very helpful; stop smoking.
• For immediate pre-exertional prophylaxis: glyceryl trinitrate sublingually or nifedipine (bite the capsule and hold the liquid in the mouth or swallow it).
• For an acute attack: glyceryl trinitrate (sublingual) or nifedipine (bite capsule, as above).
For long-term prophylaxis:
• A /^-adrenoceptor blocking drug, e.g. bisoprolol, given continuously (not merely when an attack is expected). Dosage is adjusted by response. Some put an arbitrary upper limit to dose, but others recommend that if complete relief is not obtained the dose should be raised to the maximum tolerated, provided the resting heart rate is not reduced below 55/min; or raise the dose to a level at which an increase causes no further inhibition of exercise tachycardia. In severe angina a pure antagonist, i.e. an agent lacking partial agonist activity, is preferred, since the latter may not slow the heart sufficiently. Warn the patient of the risk of abrupt withdrawal.
• A calcium-channel blocking drug, e.g. nifedipine or diltiazem, is an alternative to a p-adrenoceptor blocker: use especially if coronary spasm is suspected or if the patient has myocardial insufficiency or any bronchospastic disease. It can also be used with a p-blocker, or
• A long-acting nitrate, isosorbide dinitrate or mononitrate: use so as to avoid tolerance (p. 463).
• Nicorandil, a long-acting potassium-channel activator: this does not cause tolerance like the nitrates.
• Drug therapy may be adapted to the time of attacks, e.g. nocturnal (transdermal glyceryl trinitrate, or isosorbide mononitrate orally at night).
• Antiplatelet therapy (aspirin or clopidogrel) reduces the incidence of fatal and of nonfatal myocardial infarction in patients with unstable angina, used alone or with low-dose heparin.
• Surgical revascularisation in selected cases.
In treating angina, it is important to remember not only the objective of reducing symptoms but also that of preventing complications, particularly myocardial infarction and sudden death. This requires vigorous treatment of all risk factors (hypertension, hyperlipidaemia, diabetes mellitus) and, of course, cessation of smoking. There is little evidence that the symptomatic treatments, medical or surgical, themselves affect outcome except in patients with stenosis of the main stem of the left coronary artery, who require surgical intervention. Although aspirin has not specifically been studied in patients with stable angina, it is now reasonable to extrapolate from the studies of aspirin in other patient groups.
Was this article helpful?
Do You Suffer From High Blood Pressure? Do You Feel Like This Silent Killer Might Be Stalking You? Have you been diagnosed or pre-hypertension and hypertension? Then JOIN THE CROWD Nearly 1 in 3 adults in the United States suffer from High Blood Pressure and only 1 in 3 adults are actually aware that they have it.