Stable Angina Pectoris

Angina pectoris is a symptom complex caused by myocardial ischemia. Stable

angina refers to chest discomfort that occurs predictably and reproducibly at a
certain level of exertion and is relieved with rest or nitroglycerin. Unstable
angina includes new onset of chest pain, progressing effort angina, rest angina,
post-myocardial infarction angina, and angina after revascularization.
I.Clinical evaluation
A.Important points include the following:
1.History of previous heart disease
2.Possible non-atheromatous causes of angina (eg, aortic stenosis)
3.Symptoms of systemic atherosclerosis (eg, claudication)
4.Severity and pattern of symptoms of angina
5.Risk factors for coronary heart disease, include smoking, inappropriate
activity level, stress, hyperlipidemia, obesity, hypertension, and diabetes
mellitus.
B.Physical examination should include a cardiovascular examination,
evaluation for hyperlipidemia, hypertension, peripheral vascular disease,
congestive heart failure, anemia, and thyroid disease.
C.Laboratory studies should include an electrocardiogram and a fasting lipid
profile. Further studies may include chest films, hemoglobin, and tests for
diabetes, thyroid function, and renal function.
D.Exercise electrocardiography. An exercise test should be obtained for
prognostic information.
1.Sensitivity of exercise electrocardiography may be reduced for patients
unable to reach the level of exercise required for near maximal effort, such as:
a.Patients taking beta blockers
b.Patients in whom fatigue, dyspnea, or claudication symptoms develop
c.Patients who cannot perform leg exercises
2.Reduced specificity may be seen in patients with abnormalities on baseline
electrocardiograms, such as those taking digoxin or with left ventricular
hypertrophy or left bundle branch block.
E.Noninvasive imaging, such as myocardial perfusion scintigraphy or stress
echocardiography, may be indicated in patients unable to complete exercise
electrocardiography.
II.Medical treatment of stable angina pectoris
A.Nitrates
1.Nitrates are a first-line therapy for the treatment of acute anginal symptoms.
While they act as venodilators, coronary vasodilators, and modest arteriolar
dilators, the primary antiischemic effect of nitrates is to decrease

myocardial oxygen demand by producing systemic vasodilation more than

coronary vasodilation.
2.In combination with beta blockers or calcium channel blockers, nitrates
produce greater antianginal and antiischemic effects. There is no difference in
efficacy among preparations.
3.Sublingual nitroglycerin
a.Sublingual nitroglycerin (Nitrostat) is the therapy of choice for acute anginal
episodes and prophylactically for activities known to elicit angina.
b.The initial dose is 0.3 mg. A second dose can be taken if symptoms persist
after three to five minutes.
4.Chronic nitrate therapy
a.Chronic nitrate therapy, in the form of an oral or transdermal preparation
(isosorbide dinitrate, isosorbide mononitrate, or transdermal nitroglycerin)
can prevent or reduce the frequency of recurrent anginal episodes and improve
exercise tolerance. Chronic nitrate therapy is a second-line antianginal
therapy.
b.Isosorbide dinitrate (ISDN, Isordil SR, Dilatrate- SR, Isordil Tembids)
dosing begins with a dose of 10 mg at 8 AM, 1 PM, and 6 PM, which results in a
14 hour nitrate dose-free interval. The dose is increased to 40 mg three times
daily as needed. Alternatively, isosorbide dinitrate can be taken twice daily at 8
AM and 4 PM.
c.The extended release preparation of isosorbide mononitrate (Imdur), which is
administered once per day, may be preferable to improve compliance. The
starting dose is 30 mg once daily and can be titrated to 120 mg once daily as
needed. Some patients may develop nocturnal or rebound angina, which
requires twice daily dosing or additional antianginal therapy.
d.Transdermal nitroglycerin (Transderm-Nitro).
Use of a transdermal patch is convenient. Since most patients have angina with
activity, that the patch should be applied at 8 AM and removed at 8 PM. The
occasional patient with significant nocturnal angina can be treated with a patchon period from 8 PM to 8 AM. The initial dose is 0.2 mg per hour; the dose
can be increased to 0.8 mg per hour as needed.
Nitrate Preparations
Preparation Route of Administration
Dosage
Nitroglycerine (Nitrostat) Sublingual tab 0.15-0.9 mg
Nitroglycerine (Nitrolingual) Sublingual spray 0.4 mg
Nitroglycerine (Transderm-Nitro) Transdermal 0.2-0.8 mg/h Isosorbide
dinitrate (IsordilSR)

Oral 10-40 mg tid Isosorbide mononitrate (ISMN)

Oral 20-40 mg bid ISMN, extended release (Imdur)
Oral 30-120 mg once daily
e.Side effects associated with nitrate use are headache, lightheadedness, and
flushing.
B.Beta blockers
1.Beta blockers relieve anginal symptoms by inhibiting sympathetic stimulation
of the heart, reducing heart rate and contractility. A beta-blocker should be
initiated in patients with more frequent angina unless contraindicated.
Beta blockers should be given to virtually all patients who have had a prior MI or
who have stable heart failure.
2.Choice of agents
a.Lower doses of the cardioselective beta blockers
(atenolol and metoprolol) have the advantage of
blocking beta-1-receptor mediated stimulation of the
heart with lesser inhibition of the peripheral
vasodilation and bronchodilation induced by the beta2 receptors. A long acting cardioselective agent
(atenolol or metoprolol) is preferred for the treatment
of stable angina. There are no major advantages of
a nonselective agent, other than the low cost of
propranolol, and there are disadvantages in obstructive
lung disease, asthma, peripheral vascular
disease, diabetes, and depression.
b.Atenolol (Tenormin) starting dose is 25 mg once
daily which can be increased as tolerated to a
maximum of 200 mg once a day until the resting heart
rate is 50 to 60 beats/min and does not exceed 100
beats/min with ordinary activity.
c.Metoprolol (Lopressor) starting dose is 25 mg
BID, which can be increased to 200 mg BID as
tolerated. Extended release metoprolol (Toprol XL),
given once per day, can be substituted once an
effective dose has been established; 50-200 mg qd.
d.Beta blockers are generally well tolerated and
extremely effective in reducing anginal episodes and
improving exercise tolerance. In addition, beta
blockers are the only antianginal drugs proven to
prevent reinfarction and to improve survival in patients

who have sustained an MI.