Chronic stable angina is a common manifestation of cardiovascular disease and represents a frequent problem encountered for medical practitioners. While percutaneous coronary intervention (PCI) is routinely performed in patients with coronary artery disease (CAD), medical treatment remains the cornerstone for long term treatment. The goals of medical treatment in patients with established CAD are to: (1) reduce the frequency and severity of angina, thereby improving the quality of life; (2) reduce future cardiovascular events; and (3) improve survival. This review will specifically focus on the long term medical management of patients with chronic stable angina.

PHARMACOLOGIC TREATMENT

Medical treatment for chronic CAD is best classified as either (1) antianginal or (2) vascular protective. Antianginal medications improve exercise duration until onset of angina, decrease the severity and frequency of anginal episodes, and improve objective measures of ischaemia such as time to onset of exercise induced ST segment depression. In contrast, vascular protective medications may reduce progression of atherosclerosis and potentially stabilise coronary plaques, thereby reducing future cardiovascular events.

Antianginal medications

β-blockers

β-blockers should be first line treatment in patients with established CAD. For patients with a prior history of myocardial infarction (MI), β-blockers reduce mortality by approximately 20%.1 β-blockers are classified according to their ability to block the β₁ and/or β₂ receptors (referred to as cardiac selectivity) and the presence of additional pharmacodynamic properties (table 1).

Despite perceived contraindications such as reactive airway disease, peripheral vascular disease and diabetes mellitus, cardioselective β-blockers are well tolerated in the majority of patients.2 Absolute contraindications to β-blockers include severe bradycardia, advanced atrioventricular block, decompensated congestive heart failure and severe reactive airway disease when airway support is required. Even in the absence of perceived and absolute contraindications, the use of β-blockers in patients with established CAD remains low.3 In a large meta-analysis, β-blockers were found …