[Therapy of angina pectoris--state of the art]

A rational therapy of angina pectoris has to consider two recent pathophysiologic insights: 1. Not only in patients with instable but also with stable angina a dynamic, vasospastic component in addition to stenosis plays an important role. Stable angina is often a mixed form of disease. 2. In many patients stable angina is complicated by silent ischemia. Therapy of stable angina has 3 goals: 1. prevention or alleviation of angina; 2. reduction of silent ischemia episodes (number, extent); 3. cardioprotection i.e. prevention of instable angina, infarction and sudden death. The pharmacotherapeutic cornerstones are the nitrates, beta-blocking agents and calcium channel blockers. Their generally equivalent efficacy in short and longterm use is clinically and hemodynamically proven without doubt. Mode of action, pharmacokinetic aspects and recent as well as controversial questions regarding this group of drugs are reviewed. The pharmacotherapy of first choice should be determined for each patient individually and not according to schematic prescription. It should encompass pathogenesis of ischemia, specific indications for or adverse effects of the 3 drug classes, the question of induction of tolerance, possible cardioprotective benefit, side effects, compliance problems and finally cost of treatment. The rational aspects of combination therapy (nitrates and beta-blockers, beta-blockers and calcium antagonists) are explained and the therapeutic procedures for instable angina are outlined.