What is the optimal medical management for patients with angina?

Aspirin has been shown to reduce the risk of myocardial infarction by 87% during a 5-year follow-up in men with chronic stable angina. It should be given to all patients with angina who are without contraindications to the drug.

Aspirin and (3-blockers have both been shown to improve survival in patients with prior myocardial infarction and to reduce the incidence of reinfarction. If tolerated, (3-blockers should be used in these patients. Whether (5-blockers improve survival in patients with chronic stable angina is not clear, yet they are clearly indicated for patients with hypertension and angina and are primary therapy for effort-induced stable angina.

Nitroglycerin administered sublingually is the drug of choice for treatment of acute angina episodes. Sublingual nitroglycerin is also very effective as a prophylactic to prevent an anticipated angina attack.

Because of problems with marked variations in plasma concentration and tolerance, long-acting oral nitrates are often used as secondary therapy.

In patients with variable-threshold angina, in whom anginal episodes can occur due to increased oxygen demand or concomitant coronary vasoconstriction, a calcium channel blocker is the treatment of choice. Such patients have anginal patterns that vary considerably due to presumed vasoconstriction acting on a fixed obstructive lesion. Calcium channel blockers are also preferable in patients with variant or Prinzmetal’s angina. (3-Blockers and verapamil should be avoided in patients with overt congestive heart failure and a left ventricular ejection fraction of 30%.

Define unstable angina.

Unstable angina is a poorly defined syndrome but includes patients with either: (1) crescendo angina (more severe or frequent) superimposed on chronic stable angina; (2) angina at rest or with minimal activity; or (3) new-onset angina (within 1 month) which is brought on by minimal exertion. Unstable angina describes a very heterogenous population with single or multivessel disease, with or without prior myocardial infarction, and an uncertain outcome. Unstable angina can be classified according to severity (accelerating angina versus angina at rest, acute), clinical circumstances (secondary to other extrinsic conditions or primary), and intensity of treatment.

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