Table 2

Angina pharmacotherapy

TreatmentAngina typeExampleInvestigationMechanism of actionCommon side-effects
ß-blockersMVA, CADBisoprolol: 1.25–10 mgReduced CFR and/or structural microvascular dysfunction (raised microvascular resistance)Reduction in myocardial oxygen consumptionFatigue, blurred vision,
cold hands
Calcium channel antagonistsAllDihydropyridine (amlodipine: 2.5–10 mg daily)
Non-dihydropyridine (verapamil: 40–240 or diltiazem up to 500 mg; controlled release)
Propensity to coronary vasospasm (epicardial and/or microvascular)↓ spontaneous and inducible coronary spasm via vascular smooth muscle relaxation and ↓ oxygen demand
Vascular smooth muscle relaxation, reduction in myocardial oxygen consumption
Constipation, ankle swelling, flushing
 NitratesCAD, VSAIsosorbid mononitrate: 30–120 mg one time a day (controlled released)Propensity to epicardial coronary vasospasm↓ spontaneous and inducible coronary spasm via large epicardial vasodilation, ↓ oxygen demand. Lack of efficacy in microvascular angina with potential deleterious effectHeadaches, dizziness, flushing
 NicorandilAllNicorandil: 5–30 mg two times a dayAllPotassium channel activator with coronary microvascular dilatory effectDizziness, flushing, weakness, nausea
 Rho kinase inhibitorsVSA, CMDFasudil: 5–20 mg; three times a dayEpicardial and/or microvascular vasospasmReduce calcium sensitisation of vascular smooth muscle, maintains coronary vasodilationRashes, flushing, hypotension
Late Na+Current InhibitorsMVA, CADRanolazine: 375–500 mg two times a dayReduced CFRImproves MPRi in patients with MVA and reduced CFRNausea, dizziness, headache
If channel blockersCAD, MVAIvabradine: 2.5–7.5 mg two times a dayAllIvabradine has shown anti-ischaemic and antianginal activityBradycardia, AF, headache
Partial fatty-acid oxidation inhibitorsCAD, MVAPerhexiline: 50–400 mg daily or TrimetazidinePlasma concentration required for dose titration.Perhexiline Inhibits carnitine O-palmitoyltransferase 1 and 2, which transfer free fatty acid from the cytosol into mitochondria.Dizziness, unsteady, nausea and vomiting
Improved endothelial function/pleiotropic
 ACE inhibitorsMVA, CADRamipril: 2.5–10 mg dailyHyper-reactivity to stimuli (eg, acetylcholine, exercise, stress)Improve CFR, reduce workload, may improve small vessel remodelling. Improves endothelial vasomotor dysfunctionCough, renal impairment, hyperkalaemia
 StatinsAllAtorvastatin: 10–80 mg daily
Rosuvastatin: 5–40 mg daily
AllImproved coronary endothelial function reduced vascular inflammationMyalgia, headache, cramps
 Hormone-replacement therapy*MVAOestradiol: 1 mg dailyAngina in early menopauseOestrogen therapy improves endothelial function short-term in CMD↑ Risk of breast cancer, marginally ↑ risk of CVD
Tricyclic antidepressants (TCA)MVA with abnormal pain processingAmitriptyline: 5–10 mg nocte
Imipramine: 10–200 mg daily
AllCounteracts enhanced nociception. Thought to exert an analgesic effect on the visceral component associated with cardiac pain. Blurred vision, dry mouth, drowsiness, impaired coordination
Non-pharmacologicalAllSmoking cessation, Exercise, cardiac rehabilitation, Mediterranean diet, cognitive behavioural therapy, weight loss, YogaMetabolic syndrome, endothelial dysfunction, cardiovascular risk factors, anxiety/depressionAdjunctive non-pharmacological interventions
  • *May be helpful in some postmenopausal women. More information on experimentary pharmacotherapy in refractory angina can be found in review by Henry et al.62

  • CAD, angina with obstructive coronary artery disease; MPRi, myocardial perfusion reserve index; MVA, microvascular angina; VSA, vasospastic angina.