Medical therapy

A. One aspirin tablet daily is strongly recommended unless there are medical contraindications. In patients with mild, stable CAD, drug therapy may be limited to short-acting sublingual nitrates on an as-needed basis or prophylactically in situations known to cause angina. Use of a lower dose (0.3 mg) may reduce the incidence of side effects, such as headache or hypotension.

B. A beta-blocker is indicated in asymptomatic patients with recent myocardial infarction. The use of angiotensin-converting enzyme inhibitors has been demonstrated to be beneficial in patients with left ventricular systolic dysfunction, including that caused by myocardial infarction. Beta blockers are now recommended as first-line therapy or monotherapy for patients with stable CAD. Drugs without intrinsic sympathomimetic activity should be used. Cardioselective agents are a preferred in patients with diabetes or pulmonary disease.

1. Non-cardioselective beta-blockers a. Propranolol sustained-release (Inderal LA), 60-160-mg qd [60, 80, 120, 160 mg].

b. Nadolol (Corgard), 40-80 mg qd [20, 40, 80, 120, 160 mg].

2. Cardioselective beta-blockers a. Metoprolol (Lopressor), 100 mg bid [25, 50, 100 mg] or metoprolol XL (Toprol XL) 100-200 mg qd [50, 100, 200 mg tab ER].

b. Atenolol (Tenormin), 100 mg qd [25, 50, 100 mg].

3. Adverse Effects. Beta blockers are usually well tolerated. Symptomatic bradycardia, hypotension, fatigue, heart failure, dyspnea, cold extremities, and bronchospasm may occur. Impotence, constipation, and vivid dreams may occasionally occur.

4. Contraindications to beta-blockers a. Raynaud's phenomenon, reactive airway disease, or resting leg or foot pain caused by peripheral vascular disease.

b. Beta blockers (including cardioselective agents) can cause severe bronchospasm in patients with reactive airway disease.

C. Long-acting nitrates. If beta blockers cannot be prescribed as first-line therapy, nitrates are the preferred alternative because of their efficacy. Sublingual nitroglycerin can be used prophylactically prior to activities that are likely to precipitate angina.

1. Immediate-release nitroglycerin a. Nitroglycerin, sublingually or in spray form, is the only agent that is effective for rapid relief of an established angina attack.

b. Patients should carry nitroglycerin tablets or spray at all times and use it as needed.

c. Nitroglycerin SL (Nitrostat), 0.3-1.5 mg SL q5min prn pain [0.15, 0.3, 0.4, 0.6 mg].

d. Nitroglycerin oral spray (Nitrolingual) 1-2 sprays prn pain.

2. Nitroglycerin patches: Tolerance may be avoided by removing the patch at 2 p.m. for 8 hours each day. A minimum of 15 mg of nitro-glycerin per 24-hr period is necessary for effect. Nitroglycerin patch (Transderm-Nitro) 0.6-0.8 mg/h applied for 16 hours each day [0.4, 0.6, 0.8 mg/h patches].

a. Isosorbide dinitrate

(1) Isosorbide dinitrate slow-release, (Dilatrate-SR, Isordil Tembids) one tab bid-tid.

(2) Isosorbide dinitrate (Isordil, Titradose) 10-60 mg POtid-qid [5, 10, 20, 30, 40 mg]; sustained release, 40-80 mg PO q8-12h [40 mg].

(3) Isosorbide dinitrate immediate-release, 30 mg tid-qid.

b. Isosorbide mononitrate immediate release (ISMO, Monoket), 10 to 20 mg bid in the morning and again 7 hours later [10, 20 mg].

c. Isosorbide mononitrate extended-release (Imdur): Start with 30 mg, and increase the dose to 120 mg once daily [30, 60,120 mg].

d. Adverse effects. Nitrates are well tolerated. The most common adverse effect is headache (30-60%). Symptomatic postural hypotension may sometimes occur. Syncope may rarely occur.

D. Calcium channel blockers. For patients who are unable to take beta blockers or long-acting nitrates, the use of long-acting calcium channel blockers has been shown to be clinically effective.

1. Nifedipine XL (Procardia XL) 30-120 mg qd [30, 60, 90 mg].

2. Diltiazem SR (Cardizem SR) 60-120 mg bid [60, 90, 120 mg].

3. Diltiazem CD (Cardizem CD) 120-300 mg qd [120, 180,240,300 mg]

4. Verapamil SR (Calan SR, Isoptin SR), 120-240 mg qd [120, 180, 240 mg].

5. Diltiazem and verapamil are contraindicated in second degree or higher atrioventricular block. Calcium channel blockers should be used with caution in heart failure.

E. Combination therapy may be necessary in selected patients. A combination of beta blockers and long-acting nitrates is preferred because of efficacy and reduced potential for adverse side effects.

F. Percutaneous transluminal coronary angiography and artery bypass grafting. The relative survival benefit of CABG, compared with medical therapy, is enhanced by an increase in the absolute number of severely narrowed coronary arteries, the degree of left ventricular systolic dysfunction, and the magnitude of myocardial ischemia. No survival benefit has been documented with PTCA in stable CAD. PTCA is an alternative to medical therapy in patients with clinical evidence of ischemia and with angiographically suitable lesions.

References: See page 195.

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