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Guidelines for the Management of Patients with Chronic Stable Angina: Treatment

Stephan D. Fihn, MD, MPH; Sankey V. Williams, MD; Jennifer Daley, MD; and Raymond J. Gibbons, MD
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From VA Puget Sound Health Care System, Seattle, Washington; University of Pennsylvania, Philadelphia, Pennsylvania; Massachusetts General Hospital-Partners Health Care System, Boston, Massachusetts; and Mayo Medical Center, Rochester, Minnesota.

Copyright ©2004 by the American College of Physicians

*This paper, written by Stephan D. Fihn, MD, MPH, Sankey V. Williams, MD, Jennifer Daley, MD, and Raymond J. Gibbons, MD, was based on the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal icine Practice Guidelines for the Management of Patients with Chronic Stable Angina. Members of the Committee on Guidelines for Chronic Stable Angina were Raymond J. Gibbons, MD, Chair; Kanu Chatterjee, MB; Jennifer Daley, MD; John S. Douglas, MD; Stephan D. Fihn, MD, MPH; Julius M. Gardin, MD; Mark A. Grunwald, MD; Daniel Levy, MD; Bruce W. Lytle, MD; Robert A. O'Rourke, MD; William P. Schafer, MD; and Sankey V. Williams, MD.

Acknowledgment: The authors thank the staff at the American College of Cardiology, especially Dawn Phoubandith, for able assistance.

Requests for Single Reprints: Stephan D. Fihn, MD, MPH, NW Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System 152, 1660 South Columbian Way, Seattle, WA 98108.

Current Author Addresses: Dr. Fihn: NW Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System 152, 1660 South Columbian Way, Seattle, WA 98108.

Dr. Williams: University of Pennsylvania, 423 Guardian Drive, 1220 Blockley Hall, Philadelphia, PA 19104-2676.

Dr. Daley: Massachusetts General Hospital, 50 Stamford Street, Boston, MA 02114.

Dr. Gibbons: Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Ann Intern Med. 2001;135(8_Part_1):616-632. doi:10.7326/0003-4819-135-8_Part_1-200110160-00014
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The dual aims of treating patients with chronic stable angina are 1) to reduce morbidity and mortality and 2) to eliminate angina with minimal adverse effects and allow the patient to return to normal activities. In the absence of contraindications, β-blockers are recommended as initial therapy. All β-blockers seem to be equally effective. If the patient has serious contraindications to β-blockers, unacceptable side effects, or persistent angina, calcium antagonists should be administered. Long-acting dihydropyridine and nondihydropyridine agents are generally as effective as β-blockers in relieving angina. Long-acting nitrates are considered third-line therapy because a nitrate-free interval is required to avoid developing tolerance. All long-acting nitrates seem to be equally effective.

Patients with angina should take 75 to 325 mg of aspirin daily unless they have contraindications. Such risk factors as smoking, elevated low-density lipoprotein cholesterol level, diabetes, and hypertension should be treated appropriately.

Coronary revascularization has not been shown to improve survival for most patients with chronic angina but may be required to control symptoms. However, coronary artery bypass grafting (CABG) is often indicated for symptomatic patients with left-main disease, three-vessel disease, or two-vessel disease including proximal stenosis of the left anterior descending coronary artery; it improves their survival. Percutaneous transluminal coronary angioplasty is an alternative to CABG for patients with normal left ventricular function and favorable angiographic features. Coronary artery bypass grafting is initially more effective in relieving angina than medical therapy, but the two procedures yield similar results after 5 to 10 years. Eighty percent of patients who undergo CABG remain angina-free 5 years after surgery. In low-risk patients, percutaneous transluminal coronary angioplasty seems to control angina better than medical therapy, but recurrent angina and repeated procedures are more likely than with CABG.

Patient education is an important component of management. Long-term follow-up should be individualized to ascertain clinical stability at regular intervals and to reassess prognosis when warranted.


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Guideline for treatment of chronic stable angina.

CAD=coronary artery disease; JNC=Joint National Committee; MI=myocardial infarction; NCEP=National Cholesterol Education Program. The NCEP and JNC VI guidelines are references 4 and 5, respectively. *Medications: vasodilators, excessive thyroid replacement, and vasoconstrictors; other medical problems: profound anemia, uncontrolled hypertension, hyperthyroidism, and hypoxemia; other cardiac problems: tachyarrhythmias, bradyarrhythmias, valvular heart disease (especially aortic stenosis), and hypertrophic cardiomyopathy. **At any point in this process, on the basis of coronary anatomy, severity of anginal symptoms, and patient preferences, it is reasonable to consider evaluation for coronary revascularization. Unless a patient is documented to have left main, three-vessel, or two-vessel coronary artery disease with significant stenosis of the proximal left anterior descending coronary artery, no demonstrated survival advantage is associated with revascularization in low-risk patients with chronic stable angina; thus, medical therapy should be attempted in most patients before percutaneous transluminal coronary angioplasty or coronary artery bypass surgery is considered.

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