Rational medical therapy for stable angina pectoris

Important advances in understanding of the pathophysiology and medical treatment of angina pectoris have taken place in the past few years. Angina may occur from increased oxygen demands that cannot be met by a diseased coronary circulation and/or primary decrease in oxygen supply to the heart. Three major categories of pharmacologic agents are used in treating angina. Nitrates remain the first-line approach; they are inexpensive and available in many delivery forms. Beta blockers are also effective in the treatment of angina pectoris, and despite their side effects, are particularly useful in effort angina. The newest agents, the calcium channel blockers, are efficacious in all types of anginal syndromes. Each group of drugs acts differently on the various pathophysiologic mechanisms that contribute to the production of angina. This commentary critically reviews the major groups of anti-anginal drugs and places them in a clinical perspective. Guidelines for choosing an appropriate agent for the treatment of angina are proposed. Special situations, such as angina and hypertension, congestive heart failure, or post-myocardial infarction angina, are discussed with respect to selection of anti-anginal therapy. The proper utilization of nitrates, calcium channel blockers, and beta blockers, alone or in combination, provides a bright future for patients with ischemic heart disease.