Angina in patients with an active lifestyle

The care of the active angina patient comprises risk stratification, risk factor modification, cardiac rehabilitation and pharmacotherapy. Risk stratification may be undertaken using a symptom limited exercise test, with the possibility of myocardial perfusion imaging to improve sensitivity. Higher risk patients may be evaluated angiographically. Risk factor modification should be tailored to the individual patient and should include weight reduction, cessation of smoking, treatment of hypertension and a controlled increase in levels of exercise for the sedentary patient. Cardiac rehabilitation is comprised of patient education, risk factor management and an individualized exercise prescription, based on a symptom-limited exercise tolerance test. Exercise training is associated with measurable physiological improvements in exercise tolerance. The risk of myocardial infarction due to sudden bouts of heavy exertion is also reduced, by approximately 50-fold, in those who exercise regularly. Pharmacological management should be based on the patient's anginal threshold. Those with a high threshold may be treated symptomatically with nitroglycerin, while beta-blockers may be the most appropriate therapy for those with a lower threshold. Those with a variable threshold may respond better to calcium channel blockers. Long-acting agents are preferred, ideally providing therapeutic coverage in the morning, and throughout the day, until the next daily dose reaches therapeutic levels.