Related Experiment Video
Updated: Nov 18, 2025
Acetylcholine Re-Challenge After Intracoronary Nitroglycerine Administration
Published on: April 4, 2022
A critical appraisal of the pharmacological management of stable angina
Dimitrios Farmakis1, Andrew Xanthopoulos2, Filippos Triposkiadis2
1University of Cyprus Medical School, Nicosia, Cyprus.
Insights
This study proposes a new three-step pharmacological approach for managing chronic coronary artery disease (CAD) and stable angina. It shifts focus from plaque-centric models to a multifactorial understanding of myocardial ischemia and cardiomyocyte effects.
Area of Science:
- Cardiology
- Pharmacology
- Pathophysiology
Background:
- The traditional plaque-centric model of coronary artery disease (CAD) is increasingly challenged by evidence.
- Evidence suggests coronary artery obstruction doesn't always equate to myocardial ischemia, and ischemia can occur without obstructive lesions.
Discussion:
- A paradigm shift is needed, considering multifactorial CAD aspects like microvascular disease and cardiomyocyte ischemia.
- This paper proposes an alternative medical management approach for chronic CAD and stable angina.
- The proposed strategy integrates available anti-ischemic drugs based on myocardial ischemia pathophysiology.
Key Insights:
- Pharmacological therapy is structured in three steps: disease-modifying therapy for all chronic CAD patients.
- Pathophysiology-based anti-ischemic therapy is recommended for stable angina patients.
- Symptomatic therapy is indicated for patients with persistent anginal symptoms.
Outlook:
- This approach aims to optimize anti-ischemic drug utilization in chronic CAD management.
- Further research is needed to validate the clinical efficacy and long-term outcomes of this proposed therapeutic strategy.
- The focus shifts from solely obstructive disease to a comprehensive understanding of ischemia and its management.
Abstract:
The once dominant plaque-centric model of the pathophysiology and management of coronary artery disease (CAD) has long been questioned by a bulk of experimental and clinical evidence suggesting, among others, that coronary artery obstruction is not synonymous with myocardial ischaemia, ischaemia may occur in the absence of obstructive lesions and may persist after successful coronary revascularization, while elective revascularization provides little or no prognostic benefit. As a result, a paradigm shift has been suggested taking into consideration the multifactorial aspect of CAD such as microvascular disease and the consequences of ischemia at the level of cardiomyocyte. In this paper, we propose an alternative approach to the medical management of patients with chronic CAD and stable angina, based on the properties of the drugs currently available in the anti-ischemic armamentarium in relation to the pathophysiology of myocardial ischemia. In this approach, pharmacological therapy is organized into three steps, including disease-modifying therapy for all patients with chronic CAD, pathophysiology-based anti-ischaemic therapy for patients with stable angina and symptomatic therapy in patients with persistent anginal symptoms.
Related Concept Videos
01:26Angina IV: Management
01:20Angina V: Nursing Management
01:25Antianginal Drugs: Calcium Channel Blockers and Ranolazine
CCBs, a diverse class that includes dihydropyridines (nifedipine) and diphenylalkylamines (verapamil and diltiazem), exert their effect by blocking calcium channels in cardiac and smooth muscle cells. This...
01:16Antianginal Drugs: Nitrates and β-Blockers
Organic nitrates, such as nitroglycerin, play a pivotal role. Once metabolized, they liberate nitric oxide, a molecular marvel. Nitric oxide triggers guanylyl cyclase and augments cGMP production. This biochemical cascade orchestrates the relaxation of vascular smooth muscles, ushering in vasodilation and enhancing coronary blood flow....
01:27Coronary Artery Disease V: Interprofessional Care
01:26Atherosclerosis III: Management