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Angina Pectoris Treatment & Management

Updated: Dec 14, 2017
Author: Jamshid Alaeddini, MD, FACC, FHRS; Chief Editor: Eric H Yang, MD more...

TREATMENT

Medical Care
The main goals of treatment in angina pectoris are to relieve the symptoms, slow the progression of disease,
and reduce the possibility of future events, especially MI and premature death.

General measures
Smoking cessation results in a significant reduction of acute adverse effects on the heart and may reverse, or at
least slow, atherosclerosis. Strongly encourage patients to quit smoking, and take an active role in helping them
to achieve this goal.

Treat risk factors, including hypertension, diabetes mellitus, obesity, and hyperlipidemia.

Several clinical trials have shown that in patients with established coronary artery disease, reduction of low-
density lipoprotein (LDL) level with a beta-hydroxy-beta-methylglutaryl coenzyme A reductase inhibitor (ie,
statin) is associated with significant reductions in both mortality rate and major cardiac events. [27, 28, 29, 30]

These benefits are present even in patients with mild-to-moderate elevations of LDL cholesterol level.
Trials with cholesterol-lowering agents have confirmed the benefits of the therapeutic LDL lowering in older
persons.

Angiographic studies demonstrate that a reduction of the LDL level in patients with coronary artery disease
could cause slowing of progression, stabilization, or even regression of coronary artery lesions.

One study demonstrated a significant reduction of symptomatic myocardial ischemia in patients with unstable
angina or non–Q-wave infarction with the administration of a statin during the early acute phase.

In a study of 10,001 patients with stable coronary artery disease, an aggressive cholesterol-lowering approach
with atorvastatin 80 mg daily (mean cholesterol level of 77 mg/dL) compared to a less-aggressive approach with
atorvastatin 10 mg daily (mean cholesterol level of 101 mg/dL) resulted in a 2.2% absolute reduction and a 22%
relative reduction in the occurrence of a first major cardiovascular event (defined as death from coronary heart
disease; nonfatal, non–procedure-related myocardial infarction; resuscitation from cardiac arrest; or fatal or
nonfatal stroke). [31] This occurred with a greater incidence of elevated aminotransferase levels with the
aggressive cholesterol-lowering approach (1.2% vs 0.2%, p < 0.001).

Some triglyceride-rich lipoproteins, including partially degraded very LDL levels, are believed to be independent
risk factors for coronary artery disease. In daily practice, non-HDL cholesterol level (ie, LDL + very LDL
cholesterol [total cholesterol - HDL cholesterol]) is the most readily available measure of the total pool of these
atherogenic lipoproteins. Thus, the ATP III has identified non-HDL cholesterol level as a secondary target of
therapy in persons with high triglyceride levels (>200 mg/dL). The goal for non-HDL cholesterol level (for
persons with serum triglyceride levels >200 mg/dL) is 30 mg/dL higher than the identified LDL cholesterol level
goal.

Patients with established coronary disease and low HDL cholesterol levels are at high risk for recurrent events
and should be targeted for aggressive nonpharmacological (ie, dietary modification, weight loss, physical
exercise) and pharmacological treatment.

Several large epidemiologic studies demonstrated that HDL cholesterol levels are inversely related to
cardiovascular risk. Thus, developing pharmaceutical agents to increase the HDL level has been an attractive
target for prevention and treatment of CAD. However, several large randomized trials utilizing cholesteryl ester
transfer protein (CETP) inhibitors did not show benefit for reducing cardiovascular events in spite of raising HDL
levels. Torcetrapib has been one of CETP agents that has been used in large randomized trials. [32, 33]
Investigation of Lipid level management using coronary UltraSound To assess Reduction of Atherosclerosis by
CETP inhibition and HDL Elevation (ILLUSTRATE) was a randomized study that looked at the effect of
torcetrapib in 1188 patients with CAD who underwent intravascular ultrasonography at baseline. [32] After
treatment with atorvastatin to reduce levels of LDL cholesterol to less than 100 mg/dL, patients were randomly
assigned to receive atorvastatin monotherapy or atorvastatin plus 60 mg of torcetrapib daily.

Intravascular ultrasonography was repeated in 910 of these patients (77%) after 24 months of treatment to
evaluate the disease progression. Compared with atorvastatin monotherapy, torcetrapib–atorvastatin therapy
was associated with an impressive 61% relative increase in HDL levels and a 20% relative decrease in LDL
levels resulting in an LDL to HDL ratio of less than 1.0 in this group of patients. Despite this favorable change in
the HDL and LDL levels, among patients who underwent repeat intravascular ultrasonography, the percent
atheroma volume between the 2 groups was not different. Torcetrapib did not result in significant decrease in
the progression of coronary atherosclerosis, but it was associated with an increase in blood pressure.

Rating Atherosclerotic Disease change by Imaging with A New Cholesteryl-Ester-transfer protein inhibitor
(RADIANCE) 2, a trial reported in 2007, looked into the effect of torcetrapib on carotid atherosclerosis
progression in patients with mixed dyslipidaemia. [33] Although similar to the ILLUSTRATE trial, torcetrapib also
substantially raised HDL levels and lowered LDL levels in this study; it did not affect the progression of carotid
atherosclerosis. Similar to the ILLUSTRATE trial, torcetrapib also significantly increased systolic blood pressure.

Investigation of Lipid level management to Understand its iMpact IN ATherosclerotic Events (ILLUMINATE), an
international phase 3 study of 15,000 patients, was terminated early because it had already recorded 82 deaths
in the patients taking torcetrapib-atorvastatin compared with 51 deaths in patients taking atorvastatin alone. In
addition, the rates of MI, revascularization, angina, and heart failure were higher in the torcetrapib-atorvastatin
arm.

Due to the similar failure of multiple clinical trials focused on HDL raising, current expert thinking about HDL is
that it is to be regarded as a marker of risk rather than as a target of therapy.

Other approaches to cardiac risk factor reduction should also be used in combination with the above. Exercise
training results in improvement of symptoms, an increase in the threshold of ischemia, and improvement of
patients' sense of well-being. However, before enrolling a patient in an exercise-training program, perform an
exercise tolerance test to establish the safety of such a program.
Enteric-coated aspirin at a dose of 81 mg per day should be advised for all patients with stable angina who have
no contraindications to its use. [34, 35] In patients in whom aspirin cannot be used because of allergy or
gastrointestinal complications, consider clopidogrel. [36]

Although early observational studies suggested a cardiovascular protective effect with the use of hormone
replacement therapy, recent large randomized trials failed to demonstrate any benefit with hormone
replacement therapy in the primary or secondary prevention of cardiovascular disease. [37]

In fact, these studies even demonstrated an increased risk of coronary artery disease and stroke in patients on
hormone replacement therapy.

The Women's Health Initiative study demonstrated that the use of hormone replacement therapy for 1 year in
10,000 healthy postmenopausal women is associated with 7 more instances of coronary artery disease, 8 more
strokes, 8 more pulmonary emboli, 8 more invasive breast cancers, 5 fewer hip fractures, and 6 fewer colorectal
cancers.

Based on these data, the risks and benefits of hormone replacement therapy must be assessed on an individual
basis for each patient.

Sublingual nitroglycerin has been the mainstay of treatment for angina pectoris. Sublingual nitroglycerin can be
used for acute relief of angina and prophylactically before activities that may precipitate angina. No evidence
indicates that long-acting nitrates improve survival in patients with coronary artery disease. [38]

Beta-blockers are also used for symptomatic relief of angina and prevention of ischemic events. They work by
reducing myocardial oxygen demand and by decreasing the heart rate and myocardial contractility. Beta-
blockers have been shown to reduce the rates of mortality and morbidity following acute MI. [39] A post hoc
analysis from the ADDITIONS (prActical Daily efficacy anD safety of Procoralan In combinaTION with
betablockerS) trial demonstrated metoprolol in combination with ivabradine for treatment of patients with stable
angina was safe and effective. [40] The investigators reported a reduction in heart rate by 19.7 +/- 11.2 bpm, with
an 8-fold decrease in weekly angina attacks and nitrate use, accompanied by improvement in quality of life. [40]

Long-acting heart rate–slowing calcium channel blockers can be used to control anginal symptoms in patients
with a contraindication to beta-blockers and in those in whom symptomatic relief of angina cannot be achieved
with the use of beta-blockers, nitrates, or both. Avoid short-acting dihydropyridine calcium channel blockers
because they have been shown to increase the risk of adverse cardiac events.

Anginal symptoms in patients with Prinzmetal angina can be treated with calcium channel blockers with or
without nitrates. In one study, supplemental vitamin E added to a calcium channel blocker significantly reduced
anginal symptoms among such patients. [41]

In patients with syndrome X and hypertension, ACE inhibitors may normalize thallium perfusion defects and
increase exercise capacity. [42]

A study by Losordo et al proposes injections of autologous CD34+ cells (105 cells/kg) for patients with refractory
angina. Patients who received this experienced significant improvements in angina frequency and exercise
tolerance. [2]

Diet and activity

A diet low in saturated fat and dietary cholesterol is the mainstay of the Step I and Step II diet from
the American Heart Association.

The level of activity that aggravates anginal symptoms is different for each patient. However, most patients with
stable angina can avoid symptoms during daily activities simply by reducing the speed of activity.

Surgical Care
Revascularization therapy (ie, coronary revascularization) can be considered in patients with left main artery
stenosis greater than 50%, 2- or 3-vessel disease and LV dysfunction (ejection fraction, < 45%), poor prognostic
signs during noninvasive studies, or severe symptoms despite maximum medical therapy. The 2 main coronary
revascularization procedures are percutaneous transluminal coronary angioplasty, with or without coronary
stenting, and coronary artery bypass grafting (CABG).
Patients with 1- or 2-vessel disease and normal LV function who have anatomically suitable lesions are
candidates for percutaneous transluminal coronary angioplasty and coronary stenting. Restenosis is the major
complication, with symptomatic restenosis occurring in 20-25% of patients. Restenosis mostly occurs during the
first 6 months after the procedure and can be managed by repeat angioplasty. Several trials have demonstrated
that the use of drug-eluting stents (eg, sirolimus-eluting stents, paclitaxel-coated stents) can remarkably reduce
the rate of in-stent restenosis. With the introduction of these drug-coated stents, patients with multivessel
coronary artery disease are more frequently treated with percutaneous revascularization as opposed to the
surgical revascularization. [43, 44] More recently, some concerns have arisen that instead of improving the long-
term prognosis, drug-eluting stents might actually worsen it. In addition, stent thrombosis is a major concern
with the useofdrug-eluting stents.

A meta-analysis of individual data on 4,958 patients enrolled in 14 randomized trials comparing sirolimus-eluting
stents with bare-metal stents looked at the long-term effect of these stents. [44] The mean follow-up interval was
12.1-58.9 months. The primary end point was death from any cause. The secondary end points were stent
thrombosis, the composite end point of death or myocardial infarction, and the composite of death, MI, or a
revascularization.

The overall risk of death and the combined risk of death or MI were not significantly different for patients
receiving sirolimus-eluting stents versus bare-metal stents. A sustained reduction in the need for
revascularization occurred after the use of sirolimus-eluting stents compared with bare-metal stents. The overall
risk of stent thrombosis with sirolimus-eluting stents was not significantly higher than bare-metal stents.
However, evidence showed an increase in the risk of stent thrombosis associated with sirolimus-eluting stents
after the first year.

Patients with single-vessel disease and normal ventricular function treated with percutaneous transluminal
coronary angioplasty show improved exercise tolerance and fewer episodes of angina compared with those
who receive medical treatment. However, no difference in the frequency of MI or death has been shown
between these two groups.

The Clinical Outcomes Utilizing Revascularization and AGgressive Drug Evaluation (COURAGE) trial looked at
the benefits of PCI as an initial management strategy in patients with stable CAD. This trial was a randomized
and involved 2287 patients who had objective evidence of myocardial ischemia and significant CAD. [45] Of
these, 1149 patients were randomized to undergo PCI with optimal medical therapy (PCI group) and 1138 were
to receive optimal medical therapy alone (medical-therapy group). They were observed for 2.5-7 years (median,
4.6 y). During the follow-up, no difference was reported in the primary outcome of death from any cause and
nonfatal MI between the PCI group and the medical-therapy group. In addition, no significant differences were
noted between the 2 groups in the secondary end points of the composite of death, MI, and stroke;
hospitalization for acute coronary syndrome; or MI.

A 2012 study was prematurely halted after it showed a significant benefit in its primary endpoint (a composite of
death, myocardial infarction, or urgent revascularization) in patients with stable coronary disease who
underwent fractional flow reserve (FFR)-guided PCI plus the best available medical therapy (PCI group)
compared to those who received only the best available medical therapy alone (medical-therapy group). In this
study, patients in whom at least one stenosis was functionally significant (FFR, ≤0.80) were randomly assigned
to FFR-guided PCI plus the best available medical therapy or the best available medical therapy alone while
patients in whom all stenosis had an FFR > 0.80 received the best available medical therapy. The significant
difference in primary endpoint was driven by a lower rate of urgent revascularization in the FFR-guided PCI
patients (1.6%) than in the medical-therapy alone patients (11.1%; hazard ratio, 0.13; 95% CI, 0.06 to 0.30; P<
0.001).

Significantly fewer urgent revascularizations were triggered by a myocardial infarction or evidence of ischemia
on electrocardiography in the FFR-guided PCI group. The authors conclude that in patients with stable coronary
artery disease and functionally significant stenosis, FFR-guided PCI plus the best available medical therapy
reduces the need for urgent revascularization compared with the best available medical therapy alone. In
patients without ischemia, the outcome is favorable with the best available medical therapy alone. These results
suggest a significant role for use of FFR in patients with stable coronary artery disease to select those who
might benefit from PCI. [46]

Patients with significant left main coronary artery disease, 2- or 3-vessel disease and LV dysfunction, diabetes
mellitus, or lesions anatomically unsuitable for percutaneous transluminal coronary angioplasty have better
results with coronary artery bypass grafting. The overall operative mortality rate for coronary artery bypass
grafting is approximately 1.3%. The rate of graft patency 10 years after surgery is less than 50% for vein
grafting, although more than 90% of grafts using internal mammary arteries are patent at 10 years. In recent
years, interest has increased regarding surgery without cardiopulmonary bypass (ie, off-pump) in an attempt to
avoid the morbidity associated with cardiopulmonary bypass. A recent randomized study demonstrated that off-
pump coronary surgery was as safe as on-pump surgery and caused less myocardial damage. However, the
graft-patency rate was lower at 3 months in the off-pump group than in the on-pump group.
Laser transmyocardial revascularization

Laser transmyocardial revascularization has been used as an experimental therapy for the treatment of severe,
chronic, stable angina refractory to medical or other therapies. [5] This technique has been performed with either
an epicardial surgical technique or by a percutaneous approach. In both approaches, a series of transmural
endomyocardial channels are created to improve myocardial perfusion. The surgical transmyocardial
revascularization technique has been associated with symptomatic relief for end-stage chronic angina in the
short term. However, no published data address the long-term efficacy of surgical transmyocardial
revascularization. Nonetheless, this technique appears to provide at least symptomatic relief for end-stage
chronic angina in the short term. [47]

Human CD34+ stem cells

A subgroup of patients with coronary artery disease experiences angina that is not amenable to
revascularization and is refractory to medical therapy. Some studies have indicated that human CD34+ stem
cells induce neovascularization in ischemic myocardium enhancing perfusion and function.

The feasibility and safety of this treatment was tested in a recent phase I/IIa double-blind, randomized controlled
trial of 24 patients (19 men and 5 women aged 48-84 y) with Canadian Cardiovascular Society class 3 or 4
angina who were undergoing optimal medical treatment and who were not candidates for mechanical
revascularization. [48] Patients received granulocyte colony-stimulating factor 5 microg x kg(-1) x d(-1) for 5 days
with leukapheresis on the fifth day.

Electromechanical mapping was performed to identify ischemic but viable regions of myocardium for injection of
cells in the active treatment group versus saline injection in the placebo group. The total dose of cells was
divided in 10 intramyocardial and transendocardial injections. There was no incidence of myocardial infarction,
elevation of cardiac enzymes, perforation, or pericardial effusion. Also, there was no incidence of ventricular
tachycardia or ventricular fibrillation during the administration of granulocyte colony-stimulating factor or
intramyocardial injections.

Serious adverse events were evenly distributed between the therapy and the control groups. A trend was
demonstrated in frequency of angina, nitroglycerine usage, exercise time, and Canadian Cardiovascular Society
class that favored CD34+ cell-treated patients versus control subjects given saline injections. Based on the
results of this study a larger phase IIb study is currently under way to further evaluate this novel therapy.

Increased coronary sinus pressure

Increased coronary sinus pressure has been suggested to reduce myocardial ischemia by redistribution of
blood from nonischemic to ischemic areas. The Coronary Sinus Reducer is a percutaneous implantable device
designed to establish coronary sinus narrowing and to elevate coronary sinus pressure.

In a 2007 study, the safety and feasibility of the Coronary Sinus Reducer was evaluated in 15 patients with
coronary artery disease and refractory angina who were not candidates for revascularization. [49] All procedures
were completed successfully and no procedure-related adverse events occurred during the periprocedural and
the follow-up periods. Angina score improved in 12 of 14 patients. Also, the extent and severity of myocardial
ischemia measured by dobutamine echocardiography and by thallium single-photon emission computed
tomography was reduced significantly (p = 0.004 [n = 13] and p = 0.042 [n = 10], respectively). This study
demonstrated that the implantable Coronary Sinus Reducers may be a feasible and safe treatment for patients
with refractory angina. Further large clinical studies are needed before the use of these devices become an
accepted treatment.

Prevention
Coronary atherosclerosis is the main preventable cause of mortality in the United States. A rigorous effort to
address correctable risk factors is the mainstay of preventive cardiovascular medicine.

Smoking cessation is the single most effective preventive intervention to reduce coronary atherosclerosis
prevalence. It has been associated with a coronary artery disease reduction of 7-47% in primary prevention
settings.

Aggressive treatment of diabetes mellitus, hypertension, LV hypertrophy, hyperlipidemia, and obesity has an
important role in the prevention of coronary artery disease.

The most important recent development in coronary atherosclerosis risk modification is the introduction of
inhibitors of beta-hydroxy-beta-methylglutaryl coenzyme A reductase. Reductions of total and LDL cholesterol
levels by 25% and 35%, respectively, can achieve a similar reduction in rates of total and coronary mortality, MI,
and need for coronary revascularization.

Guidelines

References

1. [Guideline] National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National
Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002 Dec 17.
106(25):3143-421. [Medline]. [Full Text].

2. Losordo DW, Henry TD, Davidson C, et al. Intramyocardial, autologous CD34+ cell therapy for refractory
angina. Circ Res. 2011 Aug 5. 109(4):428-36. [Medline].

3. den Uil CA, Valk SD, Cheng JM, et al. Prognosis of patients undergoing cardiac surgery and treated with
intra-aortic balloon pump counterpulsation prior to surgery: a long-term follow-up study. Interact
Cardiovasc Thorac Surg. 2009 Aug. 9(2):227-31. [Medline].

4. Campbell AR, Satran D, Zenovich AG, et al. Enhanced external counterpulsation improves systolic blood
pressure in patients with refractory angina. Am Heart J. 2008 Dec. 156(6):1217-22. [Medline].

5. Oesterle SN, Sanborn TA, Ali N, et al. Percutaneous transmyocardial laser revascularisation for severe
angina: the PACIFIC randomised trial. Potential Class Improvement From Intramyocardial Channels.
Lancet. 2000 Nov 18. 356(9243):1705-10. [Medline].

6. Crea F, Pupita G, Galassi AR, et al. Role of adenosine in pathogenesis of anginal pain. Circulation. 1990
Jan. 81(1):164-72. [Medline].

7. Kugiyama K, Yasue H, Okumura K, et al. Nitric oxide activity is deficient in spasm arteries of patients with
coronary spastic angina. Circulation. 1996 Aug 1. 94(3):266-71. [Medline].
 8. Rosano GM, Collins P, Kaski JC, et al. Syndrome X in women is associated with oestrogen deficiency. Eur
Heart J. 1995 May. 16(5):610-4. [Medline].

9. Kaski JC, Elliott PM, Salomone O, et al. Concentration of circulating plasma endothelin in patients with
angina and normal coronary angiograms. Br Heart J. 1995 Dec. 74(6):620-4. [Medline].

10. Lanza GA, Giordano A, Pristipino C, et al. Abnormal cardiac adrenergic nerve function in patients with
syndrome X detected by [123I]metaiodobenzylguanidine myocardial scintigraphy. Circulation. 1997 Aug 5.
96(3):821-6. [Medline].

11. Deedwania PC, Carbajal EV. Silent ischemia during daily life is an independent predictor of mortality in
stable angina. Circulation. 1990 Mar. 81(3):748-56. [Medline].

12. Kuo L, Davis MJ, Chilian WM. Longitudinal gradients for endothelium-dependent and -independent
vascular responses in the coronary microcirculation. Circulation. 1995 Aug 1. 92(3):518-25. [Medline].

13. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics--2009 update: a report
from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
Circulation. 2009 Jan 27. 119(3):e21-181. [Medline].

14. Hemingway H, Langenberg C, Damant J, Frost C, Pyorala K, Barrett-Connor E. Prevalence of angina in

women versus men: a systematic review and meta-analysis of international variations across 31 countries.
Circulation. 2008 Mar 25. 117(12):1526-36. [Medline].

15. Tanindi A, Erkan AF, Ekici B. Epicardial adipose tissue thickness can be used to predict major adverse
cardiac events. Coron Artery Dis. 2015 Dec. 26 (8):686-91. [Medline].

16. Li Z, Liu X, Wang J, et al. Analysis of urinary metabolomic profiling for unstable angina pectoris disease
based on nuclear magnetic resonance spectroscopy. Mol Biosyst. 2015 Dec 10. 11(12):3387-96.
[Medline].

17. Gurses KM, Kocyigit D, Yalcin MU, et al. Enhanced platelet toll-like receptor 2 and 4 expression in acute
coronary syndrome and stable angina pectoris. Am J Cardiol. 2015 Dec 1. 116(11):1666-71. [Medline].
18. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol
Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004 Aug 4. 44(3):720-32.
[Medline].

19. O'Keefe JH Jr, Barnhart CS, Bateman TM. Comparison of stress echocardiography and stress myocardial
perfusion scintigraphy for diagnosing coronary artery disease and assessing its severity. Am J Cardiol.
1995 Apr 13. 75(11):25D-34D. [Medline].

20. [Guideline] Greenland P, Bonow RO, Brundage BH, et al. ACCF/AHA 2007 clinical expert consensus
document on coronary artery calcium scoring by computed tomography in global cardiovascular risk
assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology
Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000
Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with
the Society of Atherosclerosis Imaging and Prevention and the So... J Am Coll Cardiol. 2007 Jan 23.
49(3):378-402. [Medline]. [Full Text].

21. Kannel WB, Feinleib M. Natural history of angina pectoris in the Framingham study. Prognosis and
survival. Am J Cardiol. 1972 Feb. 29(2):154-63. [Medline].

22. Meijboom WB, Van Mieghem CA, van Pelt N, et al. Comprehensive assessment of coronary artery
stenoses: computed tomography coronary angiography versus conventional coronary angiography and
correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol. 2008 Aug 19.
52(8):636-43. [Medline].

23. Bamberg F, Truong QA, Blankstein R, et al. Usefulness of age and gender in the early triage of patients
with acute chest pain having cardiac computed tomographic angiography. Am J Cardiol. 2009 Nov 1.
104(9):1165-70. [Medline]. [Full Text].

24. Soran O. Alternative therapy for medically refractory angina: enhanced external counterpulsation and
transmyocardial laser revascularization. Heart Fail Clin. 2016 Jan. 12(1):107-16. [Medline].

25. Arora RR, Chou TM, Jain D, et al. The multicenter study of enhanced external counterpulsation (MUST-
EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol.
1999 Jun. 33(7):1833-40. [Medline].
26. Kumar A, Aronow WS, Vadnerkar A, et al. Effect of enhanced external counterpulsation on clinical
symptoms, quality of life, 6-minute walking distance, and echocardiographic measurements of left
ventricular systolic and diastolic function after 35 days of treatment and at 1-year follow up in 47 patients
with chronic refractory angina pectoris. Am J Ther. 2009 Mar-Apr. 16(2):116-8. [Medline].

27. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients
with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994 Nov 19.
344(8934):1383-9. [Medline].

28. Schwartz GG, Olsson AG, Ezekowitz MD, et al. Effects of atorvastatin on early recurrent ischemic events
in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA. 2001 Apr 4.
285(13):1711-8. [Medline].

29. Sever PS, Dahlof B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in
hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-
Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomi. Lancet.
2003 Apr 5. 361(9364):1149-58. [Medline].

30. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease
(PROSPER): a randomised controlled trial. Lancet. 2002 Nov 23. 360(9346):1623-30. [Medline].

31. LaRosa JC, Grundy SM, Waters DD, et al. Intensive lipid lowering with atorvastatin in patients with stable
coronary disease. N Engl J Med. 2005 Apr 7. 352(14):1425-35. [Medline].

32. Nissen SE, Tardif JC, Nicholls SJ, et al. Effect of torcetrapib on the progression of coronary
atherosclerosis. N Engl J Med. 2007 Mar 29. 356(13):1304-16. [Medline].

33. Bots ML, Visseren FL, Evans GW, et al. Torcetrapib and carotid intima-media thickness in mixed
dyslipidaemia (RADIANCE 2 study): a randomised, double-blind trial. Lancet. 2007 Jul 14. 370(9582):153-
60. [Medline].

34. Ridker PM, Manson JE, Gaziano JM, et al. Low-dose aspirin therapy for chronic stable angina. A
randomized, placebo-controlled clinical trial. Ann Intern Med. 1991 May 15. 114(10):835-9. [Medline].
35. Juul-Moller S, Edvardsson N, Jahnmatz B, et al. Double-blind trial of aspirin in primary prevention of
myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin
Trial (SAPAT) Group. Lancet. 1992 Dec 12. 340(8833):1421-5. [Medline].

36. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute
coronary syndromes without ST-segment elevation. N Engl J Med. 2001 Aug 16. 345(7):494-502.
[Medline].

37. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy
postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial.
JAMA. 2002 Jul 17. 288(3):321-33. [Medline].

38. Lacoste LL, Theroux P, Lidon RM, et al. Antithrombotic properties of transdermal nitroglycerin in stable
angina pectoris. Am J Cardiol. 1994 Jun 1. 73(15):1058-62. [Medline].

39. Norwegian Multicenter Study Group. Timolol-induced reduction in mortality and reinfarction in patients
surviving acute myocardial infarction. N Engl J Med. 1981 Apr 2. 304(14):801-7. [Medline].

40. Werdan K, Ebelt H, Nuding S, et al, for the ADDITIONS Study Investigators. Ivabradine in Combination
with Metoprolol Improves Symptoms and Quality of Life in Patients with Stable Angina Pectoris: A post
hoc Analysis from the ADDITIONS Trial. Cardiology. 2016. 133(2):83-90. [Medline].

41. Miwa K, Miyagi Y, Igawa A, et al. Vitamin E deficiency in variant angina. Circulation. 1996 Jul 1. 94(1):14-
8. [Medline].

42. Kaski JC, Rosano G, Gavrielides S, Chen L. Effects of angiotensin-converting enzyme inhibition on
exercise-induced angina and ST segment depression in patients with microvascular angina. J Am Coll
Cardiol. 1994 Mar 1. 23(3):652-7. [Medline].

43. Morice MC, Serruys PW, Sousa JE, et al. A randomized comparison of a sirolimus-eluting stent with a
standard stent for coronary revascularization. N Engl J Med. 2002 Jun 6. 346(23):1773-80. [Medline].

44. Kastrati A, Mehilli J, Pache J, et al. Analysis of 14 trials comparing sirolimus-eluting stents with bare-metal
stents. N Engl J Med. 2007 Mar 8. 356(10):1030-9. [Medline].
45. Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary
disease. COURAGE Trial Research Group. N Engl J Med. 2007 Apr 12. 356(15):1503-16. [Medline].

46. De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in
stable coronary disease. N Engl J Med. 2012 Sep 13. 367(11):991-1001. [Medline].

47. Allen KB, Dowling RD, Fudge TL, et al. Comparison of transmyocardial revascularization with medical
therapy in patients with refractory angina. N Engl J Med. 1999 Sep 30. 341(14):1029-36. [Medline].

48. Losordo DW, Schatz RA, White CJ, et al. Intramyocardial transplantation of autologous CD34+ stem cells
for intractable angina: a phase I/IIa double-blind, randomized controlled trial. Circulation. 2007 Jun 26.
115(25):3165-72. [Medline].

49. Banai S, Ben Muvhar S, Parikh KH, et al. Coronary sinus reducer stent for the treatment of chronic
refractory angina pectoris: a prospective, open-label, multicenter, safety feasibility first-in-man study. J Am
Coll Cardiol. 2007 May 1. 49(17):1783-9. [Medline].

50. [Guideline] Stone NJ, Robinson JG, Lichtenstein AH, et al, American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood
cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 24.
129(25 Suppl 2):S1-45. [Medline]. [Full Text].

51. [Guideline] Jellinger PS, Smith DA, Mehta AE, et al, for the AACE Task Force for Management of
Dyslipidemia and Prevention of Atherosclerosis. American Association of Clinical Endocrinologists'
Guidelines for Management of Dyslipidemia and Prevention of Atherosclerosis. Endocr Pract. 2012 Mar-
Apr. 18(Suppl 1):1-78. [Medline]. [Full Text].

52. [Guideline] Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-
centered management of dyslipidemia: part 1 - executive summary. J Clin Lipidol. 2014 Sep-Oct. 8(5):473-
88. [Medline]. [Full Text].

53. [Guideline] Fihn SD, Gardin JM, Abrams J,et al, American College of Cardiology Foundation/American
Heart Association Task Force. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis
 and management of patients with stable ischemic heart disease: a report of the American College of
Cardiology Foundation/American Heart Association task force on practice guidelines, and the American
College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
Circulation. 2012 Dec 18. 126(25):e354-471. [Medline]. [Full Text].

54. [Guideline] Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS
focused update of the guideline for the diagnosis and management of patients with stable ischemic heart
disease: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular
Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic
Surgeons. Circulation. 2014 Nov 4. 130(19):1749-67. [Medline]. [Full Text].

55. [Guideline] Montalescot G, Sechtem U, Achenbach S, et al, Task Force on the Management of Stable
Coronary Artery Disease of the European Society of Cardiology. 2013 ESC guidelines on the management
of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of
the European Society of Cardiology. Eur Heart J. 2013 Oct. 34(38):2949-3003. [Medline]. [Full Text].

56. [Guideline] Windecker S, Kolh P, Alfonso F, et al, for the Task Force on Myocardial Revascularization of
the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery
(EACTS). Developed with the special contribution of the Europ. 2014 ESC/EACTS guidelines on
myocardial revascularization. Eur Heart J. 2014 Oct 1. 35(37):2541-619. [Medline]. [Full Text].

57. [Guideline] Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of
dual antiplatelet therapy in patients with coronary artery disease: a report of the ACC/AHA Task Force on
Clinical Practice Guidelines. Circulation. 2016 Sep 6. 134(10):e123-55. [Medline]. [Full Text].

58. Anderson HV. Angiotensin-converting enzyme inhibitors: ischemia is not the correct measure of benefit. J
Am Coll Cardiol. 2003 Dec 17. 42(12):2060-2. [Medline].

59. Khan NA, Hemmelgarn B, Herman RJ, et al. The 2009 Canadian Hypertension Education Program
recommendations for the management of hypertension: Part 2--therapy. Can J Cardiol. 2009 May.
25(5):287-98. [Medline]. [Full Text].
60. Ambrosio G, Betocchi S, Pace L, et al. Prolonged impairment of regional contractile function after
resolution of exercise-induced angina. Evidence of myocardial stunning in patients with coronary artery
disease. Circulation. 1996 Nov 15. 94(10):2455-64. [Medline].

61. Boggs W. Coronary CT angiography, or usual care, in the ED? Medscape Medical News. February 6,
2013. Available at http://www.medscape.com/viewarticle/778873. Accessed: March 25, 2013.

62. Brown G, Albers JJ, Fisher LD, et al. Regression of coronary artery disease as a result of intensive lipid-
lowering therapy in men with high levels of apolipoprotein B. N Engl J Med. 1990 Nov 8. 323(19):1289-98.
[Medline].

63. Califf RM, Armstrong PW, Carver JR, et al. 27th Bethesda Conference: matching the intensity of risk factor
management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high,
medium and low risk subgroups for purposes of risk factor management. J Am Coll Cardiol. 1996 Apr.
27(5):1007-19. [Medline].

64. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after
acute coronary syndromes. N Engl J Med. 2004 Apr 8. 350(15):1495-504. [Medline].

65. Chauhan A, Mullins PA, Taylor G, et al. Both endothelium-dependent and endothelium-independent
function is impaired in patients with angina pectoris and normal coronary angiograms. Eur Heart J. 1997
Jan. 18(1):60-8. [Medline].

66. Connolly DC, Elveback LR, Oxman HA. Coronary heart disease in residents of Rochester, Minnesota. IV.
Prognostic value of the resting electrocardiogram at the time of initial diagnosis of angina pectoris. Mayo
Clin Proc. 1984 Apr. 59(4):247-50. [Medline].

67. Frileux S, Munoz Sastre MT, Mullet E, Sorum PC. The impact of the preventive medical message on
intention to change behavior. Patient Educ Couns. 2004 Jan. 52(1):79-88. [Medline].

68. Hulten E, Pickett C, Bittencourt MS, et al. Outcomes after coronary computed tomography angiography in
the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am
Coll Cardiol. 2013 Feb 26. 61(8):880-92. [Medline].
69. Khan NE, De Souza A, Mister R, et al. A randomized comparison of off-pump and on-pump multivessel
coronary-artery bypass surgery. N Engl J Med. 2004 Jan 1. 350(1):21-8. [Medline].

70. Margolis JR, Chen JT, Kong Y, et al. The diagnostic and prognostic significance of coronary artery
calcification. A report of 800 cases. Radiology. 1980 Dec. 137(3):609-16. [Medline].

71. Mark DB, Califf RM, Morris KG, et al. Clinical characteristics and long-term survival of patients with variant
angina. Circulation. 1984 May. 69(5):880-8. [Medline].

72. Maseri A, Crea F, Kaski JC, Davies G. Mechanisms and significance of cardiac ischemic pain. Prog
Cardiovasc Dis. 1992 Jul-Aug. 35(1):1-18. [Medline].

73. Piatti P, Fragasso G, Monti LD, et al. Endothelial and metabolic characteristics of patients with angina and
angiographically normal coronary arteries: comparison with subjects with insulin resistance syndrome and
normal controls. J Am Coll Cardiol. 1999 Nov 1. 34(5):1452-60. [Medline].

74. Rocco MB, Nabel EG, Campbell S, et al. Prognostic importance of myocardial ischemia detected by
ambulatory monitoring in patients with stable coronary artery disease. Circulation. 1988 Oct. 78(4):877-84.
[Medline].

75. Rubins HB, Robins SJ, Collins D, et al. Gemfibrozil for the secondary prevention of coronary heart disease
in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein
Cholesterol Intervention Trial Study Group. N Engl J Med. 1999 Aug 5. 341(6):410-8. [Medline].

76. Wenger NK, Speroff L, Packard B. Cardiovascular health and disease in women. N Engl J Med. 1993 Jul
22. 329(4):247-56. [Medline].

77. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on

cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study
Investigators. N Engl J Med. 2000 Jan 20. 342(3):145-53. [Medline].

78. Kovarnik T, Chen Z, Mintz GS, et al. Plaque volume and plaque risk profile in diabetic vs. non-diabetic
patients undergoing lipid-lowering therapy: a study based on 3D intravascular ultrasound and virtual
histology. Cardiovasc Diabetol. 2017 Dec 7. 16(1):156. [Medline].
 79. Konigstein M, Giannini F, Banai S. The Reducer device in patients with angina pectoris: mechanisms,
indications, and perspectives. Eur Heart J. 2017 Aug 31. [Medline].

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Contributor Information and Disclosures

Author

Jamshid Alaeddini, MD, FACC, FHRS Director, Cardiac Electrophysiology Services, Lake Health System

Jamshid Alaeddini, MD, FACC, FHRS is a member of the following medical societies: American College of
Cardiology, American Heart Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jamshid Shirani, MD Director of Cardiology Fellowship Program, Director of Echocardiography Laboratory,

Director of Hypertrophic Cardiomyopathy Clinic, St Luke's University Health Network

Jamshid Shirani, MD is a member of the following medical societies: American Association for the Advancement
of Science, American Federation for Medical Research, American Society of Echocardiography, Association of
Subspecialty Professors, American College of Cardiology, American College of Physicians, American Heart
Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center
College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Yasmine Subhi Ali, MD, FACC, FACP, MSCI President, Nashville Preventive Cardiology, PLLC; Assistant
Clinical Professor of Medicine, Vanderbilt University School of Medicine

Yasmine Subhi Ali, MD, FACC, FACP, MSCI is a member of the following medical societies: American College
of Cardiology, American College of Physicians, American Heart Association, American Medical Association,
National Lipid Association, Tennessee Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: MCG Health,
LLC<br/>Received income in an amount equal to or greater than $250 from: Verywell.com.

Chief Editor

Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and
Interventional Cardiology, Mayo Clinic Arizona

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.