Document Detail

Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization.
MedLine Citation:
PMID:  20859545     Owner:  NLM     Status:  MEDLINE    
The objectives in treating angina are relief of pain and prevention of disease progression through risk reduction. Mechanisms, indications, clinical forms, doses, and side effects of the traditional antianginal agents - nitrates, β-blockers, and calcium channel blockers - are reviewed. A number of patients have contraindications or remain unrelieved from anginal discomfort with these drugs. Among newer alternatives, ranolazine, recently approved in the United States, indirectly prevents the intracellular calcium overload involved in cardiac ischemia and is a welcome addition to available treatments. None, however, are disease-modifying agents. Two options for refractory angina, enhanced external counterpulsation and spinal cord stimulation (SCS), are presented in detail. They are both well-studied and are effective means of treating at least some patients with this perplexing form of angina. Traditional modifiable risk factors for coronary artery disease (CAD) - smoking, hypertension, dyslipidemia, diabetes, and obesity - account for most of the population-attributable risk. Individual therapy of high-risk patients differs from population-wide efforts to prevent risk factors from appearing or reducing their severity, in order to lower the national burden of disease. Current American College of Cardiology/American Heart Association guidelines to lower risk in patients with chronic angina are reviewed. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial showed that in patients with stable angina, optimal medical therapy alone and percutaneous coronary intervention (PCI) with medical therapy were equal in preventing myocardial infarction and death. The integration of COURAGE results into current practice is discussed. For patients who are unstable, with very high risk, with left main coronary artery lesions, in whom medical therapy fails, and in those with acute coronary syndromes, PCI is indicated. Asymptomatic patients with CAD and those with stable angina may defer intervention without additional risk to see if they will improve on optimum medical therapy. For many patients, coronary artery bypass surgery offers the best opportunity for relieving angina, reducing the need for additional revascularization procedures and improving survival. Optimal medical therapy, percutaneous coronary intervention, and surgery are not competing therapies, but are complementary and form a continuum, each filling an important evidence-based need in modern comprehensive management.
Richard Kones
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Publication Detail:
Type:  Journal Article; Review     Date:  2010-09-07
Journal Detail:
Title:  Vascular health and risk management     Volume:  6     ISSN:  1178-2048     ISO Abbreviation:  Vasc Health Risk Manag     Publication Date:  2010  
Date Detail:
Created Date:  2010-09-22     Completed Date:  2010-12-03     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101273479     Medline TA:  Vasc Health Risk Manag     Country:  New Zealand    
Other Details:
Languages:  eng     Pagination:  749-74     Citation Subset:  IM    
Cardiometabolic Research Institute, Houston, Texas 77055, USA.
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MeSH Terms
Adrenergic beta-Antagonists / adverse effects,  therapeutic use
Angina Pectoris / drug therapy,  prevention & control,  surgery,  therapy*
Calcium Channel Blockers / therapeutic use
Health Behavior
Myocardial Revascularization*
Nitrates / therapeutic use
Primary Prevention
Risk Factors
Treatment Failure
Vasodilator Agents / therapeutic use*
Reg. No./Substance:
0/Adrenergic beta-Antagonists; 0/Calcium Channel Blockers; 0/Nitrates; 0/Vasodilator Agents
Comment In:
Vasc Health Risk Manag. 2011;7:135-6   [PMID:  21468173 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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