Medical Management of Stable Angina; the Old and the New

The medical therapy of stable angina aims to address the key factor mediating myocardial ischemia: oxygen supply/demand imbalance. Understanding cardiac pain requires knowledge of the interplay of ischemic, metabolic, and neurologic mechanisms. In this presentation, I shall focus on ischemic and metabolic mechanisms and their therapy. Management of patients with chronic stable angina has two main objectives:

1) symptomatic relief from ischemia; and (2) cardiovascular risk reduction and improvement of prognosis. These objectives are modulated by two different mechanisms: symptoms of ischemia are due to an insufficient oxygen supply/demand ratio, while acute coronary syndromes are due to vulnerable plaque erosion and rupture, resulting in thrombotic coronary occlusion.

Traditional anti-ischemic therapy includes three antianginal agents: nitrates, ß-blockers, and calcium-channel blockers (CCBs). The traditional agents reduce angina symptoms and prolong exercise duration and/or time to ST-segment depression on the electrocardiogram. Frequently, a combination of these drugs is necessary for symptom control, but hard data on the use of all three classes together are lacking. None of these drugs has been shown to be disease-modifying; they do not change the risk of myocardial infarction, sudden cardiac death, or all-cause mortality.