The multifaceted angina.

Abstract

The word angina describes a symptom most of the time, but not exclusively, due to myocardial ischaemia. The first, lucid, description of angina goes back to 1772 when Heberdeen wrote: ‘There is a disorder of the breast… The seat of it, and sense of strangling and anxiety, with which is attended, may make it not improperly be called angina pectoris. Those, who are afflicted with it, are ceased [sic] while they are walking and most particularly when they walk soon after eating, with a painful and most disagreeable sensation in the breast, which seems as it would take their breathe away, if it were to increase or to continue; the moment they standstill, all this uneasiness vanishes’.1 The definition used today for angina is not very different.2 Whatever the definition in guidelines or text book, the reality is that angina can be perceived by patients in many different ways. This is because: (i) not all patients with angina are the same (they might have different comorbidities, different perception of pain); (ii) not all the anginal attacks are the same (as they may be precipitated by several different mechanisms); and (iii) not all the ischaemic episodes are the same. The aim of this supplement of the European Heart Journal, the Heart of the Matter is to provide a spectrum of the multiple facets of angina. To this end, a group of experts with experience and interest in chronic stable angina met at the University of Ferrara, Italy to present and discuss several clinical cases which are all reported in the supplement. It follows that, the symptomatic pharmacological treatment of patients with angina cannot be the same for all patients, instead it has to be personalized. Current clinical guidelines recommend antianginal therapy to control symptoms of angina before considering coronary artery revascularization,3–5 following a categorical first- and second-line approach (Figure 1). Drugs that are classified first line are beta-blockers, calcium channel blockers, and short acting nitrates. The second line are long-acting nitrates, ivabradine, nicorandil, ranolazine, and trimetazidine. Second-line drugs are indicated for patients who have contraindications to first line agents, do not tolerate them or remain symptomatic. This categorical approach has been questioned in the past couple of years.6–10 Newer antianginal drugs, which are classified as second choice, have more evidence-based and more contemporary data to support their use than what is available for the traditional first-choice drugs. Recently, systematic reviews covering 50 years of medical treatment of angina were performed,10 which demonstrated an incredible scarcity of data since only 72 controlled randomized studies comparing two antianginal drugs were identified including a total of 7034 patients since 1964 to the current day.11,12 Furthermore, only 13 studies included between 100 and 300 patients with more than 50 patients per group, a minimum number to perform a meaningful comparison among groups. The results clearly indicate that, from the little data that there is, no superiority of one antianginal agent over another has been shown and equivalence is demonstrated among beta-blockers, calcium antagonists, and If channel inhibitors. This, in turn, suggests that the treatment of chronic patients can be achieved with all the available class of drugs tailoring these to the patients’ characteristics, comorbidities, and to the typology of resulting ischaemia. This is the reason why the authors of the present supplement decided to propose a different, more individualized approach to patients with angina, the so-called ‘Diamond approach to personalized treatment of angina’.10 Open in a separate window Figure 1 Current guideline suggestions for the symptomatic medical treatment of angina pectoris. © LLS 201822.