Optimizing Management of Stable Angina: Key Points
The following are key points to remember from a state-of-the-art review on optimizing management of stable angina:
- Stable angina pectoris may arise from obstructive coronary artery disease (CAD) or in the absence of significant CAD (ischemia with nonobstructed coronary arteries [INOCA]). This expert opinion paper reviews the evidence for the management of angina, highlighting the complementary role of coronary revascularization, optimal medical therapy, and lifestyle interventions and underscoring the importance of a personalized approach that targets the underlying pathobiology.
- Therapeutic strategies for patients with angina and obstructive CAD focus on reducing cardiovascular (CV) events and relieving symptoms, whereas in INOCA, the focus shifts toward managing functional alterations of the coronary circulation. The primary objectives of therapeutic strategies in angina with obstructive CAD are 2-fold: to reduce the risk of CV events, and to alleviate angina symptoms and exercise-induced ischemia.
- Patients should initially undergo coronary computed tomographic angiography to rule out the presence of left main disease or extensive three-vessel CAD in diabetic patients. Echocardiography should be performed to detect any severe left ventricular (LV) dysfunction caused by obstructive CAD (LV ejection fraction <35%) or any other cardiac condition that may cause symptoms (e.g., valvular heart disease, cardiomyopathies).
- In obstructive CAD, coronary revascularization might improve angina status, although a significant percentage of patients present with angina persistence or recurrence, suggesting the presence of functional mechanisms along with epicardial CAD.
- Selecting the most effective antianginal regimen is crucial to achieving the expected clinical benefit, minimize side effects, and enhance medication adherence. US guidelines recommend initiating with either beta-blockers, calcium channel blockers, or long-acting nitrates, with the addition of a second antianginal agent from a different class or ranolazine if symptoms persist.
- Of importance, a key aspect of correct management is the routine evaluation of therapy effectiveness at 2- to 3-month intervals. During these assessments, therapy should be up-titrated if symptoms are not adequately controlled or if first-line agents cannot be tolerated.
- In patients with INOCA, performing a precise endotype diagnosis is crucial to allow a tailored therapy targeted toward the specific pathogenic mechanism. While no disease-modifying therapies have been specifically designed for INOCA yet, the diagnosis of the specific INOCA endotype is critical for providing personalized treatment and enhancing prognosis.
- For all patients, the achievement of optimal CV risk factor control through lifestyle intervention (diet, exercise, and smoking cessation) and guideline-directed pharmacologic secondary prevention targeting hypertension, dyslipidemia, and diabetes is essential to reduce CV events and improve prognosis.
- An integrated care model that encompasses medical treatments, lifestyle changes, and procedural interventions is crucial for a comprehensive strategy in managing these patients.
- A structured patient-centric paradigm represents a significant advancement in angina management, combining the best of optimal medical therapy and revascularization to ensure the most effective and safe treatment for each unique individual
