Angina Pectoris – Drug Management (AKI Level)

1. Core Principles (Always Start Here)

Stable angina management has two parallel goals:

• Prognostic benefit (reduce MI/death)
• Symptom control (reduce angina episodes)

Prognostic Drugs (MUST KNOW)

• Aspirin (75 mg daily)
  → Antiplatelet → ↓ thrombus formation on atherosclerotic plaque
• Statin (e.g. atorvastatin 80 mg)
  → ↓ LDL + plaque stabilisation

Consider:

• ACE inhibitor if co-existing:
  • Diabetes
  • Hypertension
  • LV dysfunction

---

2. Symptom Relief – Acute Attack

Sublingual Nitrates

• Glyceryl trinitrate (GTN) spray/tablet
  → Rapid venodilation → ↓ preload → ↓ myocardial oxygen demand

Key exam points:

• Works within minutes
• Can be used prophylactically before exertion
• Side effects: headache, flushing, hypotension

---

3. First-Line Long-Term Anti-Anginal Therapy

NICE: Choose ONE initially based on patient factors:

Option A: Beta-blocker

• e.g. Atenolol, bisoprolol
• Mechanism:
  • ↓ heart rate
  • ↓ contractility
    → ↓ myocardial oxygen demand

Indications:

• Post-MI
• Tachycardia

Avoid in:

• Asthma
• Severe bradycardia
• AV block

---

Option B: Calcium Channel Blocker (CCB)

Rate-limiting CCBs

• Verapamil
• Diltiazem

Mechanism:

• ↓ heart rate + vasodilation

Use as monotherapy alternative to beta-blockers

---

⚠️ High-Yield Safety Rule

• DO NOT combine beta-blocker + verapamil
  → Risk of complete heart block + severe bradycardia

---

4. Combination Therapy (If Symptoms Persist)

Step-up Strategy:

If inadequate control on one drug:

• Beta-blocker + DHP CCB
  • e.g. Amlodipine
  • or modified-release nifedipine

Why DHP?

• Causes vasodilation WITHOUT significant heart rate reduction
  → safer with beta-blockers

---

5. Second-Line (Add-on or Alternatives)

Used when:

• First-line drugs contraindicated OR
• Symptoms persist

Options to KNOW:

1. Long-acting nitrates

• e.g. isosorbide mononitrate
  → Venodilation → ↓ preload

---

2. Ivabradine

• Selectively ↓ heart rate (SA node)
• Use if:
  • Cannot tolerate beta-blockers
  • Sinus rhythm required

---

3. Nicorandil

• Dual action:
  • Nitrate-like
  • K⁺ channel activation → vasodilation

---

4. Ranolazine

• Improves myocardial efficiency
• No major effect on HR or BP
  → useful in hypotensive patients

---

6. Triple Therapy Rule (Exam Favourite)

If patient is on:

• Beta-blocker + CCB

→ Only add a third anti-anginal:

• Short-term while awaiting revascularisation
  • PCI
  • CABG

---

7. Nitrate Tolerance (Very High Yield)

Mechanism:

• Continuous nitrate exposure → ↓ responsiveness

Prevention Strategy:

• “Nitrate-free interval” = 10–14 hours daily

Example:

• Asymmetric dosing (morning + afternoon, no night dose)

Important Exception:

• Modified-release isosorbide mononitrate → less tolerance issue

---

8. Exam Algorithm (Quick Recall)

1. All patients:
   • Aspirin + statin + GTN PRN
2. First-line:
   • Beta-blocker OR rate-limiting CCB
3. If not controlled:
   • Combine BB + DHP-CCB
4. If still symptomatic / intolerant:
   • Add:
     • Nitrate / ivabradine / nicorandil / ranolazine
5. Persistent symptoms:
   • Refer for PCI/CABG

---

9. Classic Exam Traps

• ❌ Beta-blocker + verapamil → heart block
• ❌ Nitrates + sildenafil → severe hypotension
• ❌ Beta-blockers in asthma → bronchospasm
• ❌ Ivabradine requires sinus rhythm