Abstract
Over the last 20 years, it has emerged that, while surgical revascularisation of extensive ischaemic heart disease may have prognostic advantages, the main issues considered regarding individual management are usually those of symptomatic improvement only. The major impetus towards invasive intervention is therefore failure of prophylactic anti-anginal therapy. On the other hand, many patients, especially the elderly, now present the clinical problem of ongoing angina without residual invasive options. There is an ongoing need for more effective anti-anginal therapies. Of the currently available major classes of prophylactic anti-anginal agents, neither nitrates, β-blockers nor calcium antagonists generally produce marked improvements in exercise duration. Three areas of new therapeutic development in anti-anginal therapy are worthy of note. These involve the sinus node inhibitor ivabradine, high dose allopurinol (xanthine oxidase inhibitor) and a new class of “metabolic modulators” represented by perhexiline, trimetazidine and probably ranolazine. The current review addresses the therapeutic potential of these agents. Notably, all of these “new” drugs are potentially suitable for management of angina in the setting of impaired left ventricular systolic function, and they may also be utilized in patients with angina independent of the presence of coronary disease (for example in hypertrophic cardiomyopathy). The current evidence for efficacy and potential future development in this area are reviewed.
Highlights
“If I were an ischaemic cardiac cell, and someone offered me drugs or blood, I think I’d take blood!” —Dr W
The history of development of anti-ischaemic therapy for angina pectoris has been bedevilled by the notion that a strategy of predominantly medical treatment is essentially palliative, while interventional restoration of normal coronary haemodynamics is “curative”
If the major efficacy of drugs of surgical/percutaneous intervention relates to amelioration of symptoms in patients with angina, how effective are our “core” medical anti-anginal therapies? The major groups of prophylactic anti-anginal agents are long-acting nitrates, β-blockers and calcium antagonists
Summary
“If I were an ischaemic cardiac cell, and someone offered me drugs or blood, I think I’d take blood!” —Dr W. If the major efficacy of drugs of surgical/percutaneous intervention relates to amelioration of symptoms in patients with angina, how effective are our “core” medical anti-anginal therapies? These show that long-acting nitrates and β-blockers induce only small prolongations of exercise duration, while both verapamil and diltiazem are a little more effective. The clinical characteristics of patients treated medically for angina pectoris have evolved with the relatively widespread availability of coronary surgery/stenting. In most societies, such patients tend to be elderly, with multiple comorbidities. Carvedilol (50 mg) Bisoprolol: 10 mg 20 mg Acebutolol (1155 mg) Atenolol (100 - 200 mg)
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