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Vascular Health and Risk Management

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Recent advances in the management of chronic
stable angina ii. Anti-ischemic therapy, options for
refractory angina, risk factor reduction,
and revascularization
This article was published in the following Dove Press journal:
Vascular Health and RiskManagement
11 August 2010
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Richard Kones
The Cardiometabolic Research
institute, Houston, Texas, USA

Correspondence: Richard Kones MD
Cardiometabolic Research institute, 8181
Fannin St, U314 Houston, TX 77055, USA
Tel +1 713 790 9100
Fax +1 713 790 9292
email drrkones@comcast.net

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Dovepress11100

Abstract: 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 discomfortwith 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 indetail. 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 highrisk patients differs from population-wide effortsto 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,
PCIis 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.
Keywords: coronary artery disease, ischemic heart disease, myocardial oxygen balance,
cardiovascular risk reduction, acute coronary syndrome, COURAGE study, percutaneous
coronary intervention,revascularization, nitrates, β-blockers, calcium channel blockers,
ranolazine, refractory angina, prevention of heart disease, coronary artery bypass surgery,
primordial prevention, statin drugs
Vascular Health and Risk Management 2010:6 749–774
© 2010 Kones, publisher and licensee Dove Medical Press Ltd. This is an Open Access article
which permits unrestricted noncommercial use, provided the...