Bill is a 58yo male recently diagnosed with stable angina.  He has been experiencing chest pain about 2-3 times per week for the last month.  His chest pain typically occurs while walking, which he does about 3 times each week.

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Bill is a 58yo male recently diagnosed with stable angina.  He has been experiencing chest pain about 2-3 times per week for the last month.  His chest pain typically occurs while walking, which he does about 3 times each week.  He has no other significant past medical history, takes no medications, has no drug allergies, and does not smoke.  His BP is 122/74, HR 72.  His labs are all normal.  His fasting lipid profile is Total Cholesterol 175, HDL 45, LDL 90, TG 125.  Waist circumference is 30”, and BMI is 24.  His family history is unremarkable.

  1. What risk factors are present and are they modifiable?
  2. What are the goals of therapy?
  3. What medication(s) do you recommend to prevent Bill from experiencing angina-related chest discomfort and to increase exercise capacity?
  4. What do you recommend to treat acute episodes of stable-angina-related chest discomfort?
  5. What additional medications can improve outcomes (e.g. decreased cardiovascular mortality, non-fatal MI, cardiac arrest, etc.) in a patient like Bill who has stable angina?
  6. What is your drug therapy monitoring plan?
  7. What patient education should you provide?

  8. Risk Factors and Their Modifiability

    Bill’s current risk factors for coronary artery disease (CAD) are minimal. However, age (58 years) is a non-modifiable risk factor. Although his lipid profile is within normal limits, his HDL (45 mg/dL) is borderline low, and low HDL is associated with increased cardiovascular risk (Grundy et al., 2019). This factor is modifiable through exercise and dietary interventions. Bill’s lack of medication and no smoking history are positive factors. He maintains a healthy BMI (24) and waist circumference (30”), indicating low risk for metabolic syndrome.

    Goals of Therapy

    The primary goals of therapy for stable angina are to (1) reduce the frequency and severity of angina, (2) improve functional capacity and quality of life, and (3) prevent cardiovascular events such as myocardial infarction and death (Fihn et al., 2012).

    Recommended Medications to Prevent Angina and Increase Exercise Capacity

    First-line pharmacologic treatment includes a beta-blocker, such as metoprolol succinate 50–100 mg daily, which reduces myocardial oxygen demand by decreasing heart rate and contractility (Fihn et al., 2012). If beta-blockers are contraindicated or not tolerated, calcium channel blockers (e.g., amlodipine) or long-acting nitrates (e.g., isosorbide mononitrate) can be used. Ranolazine may also be considered if symptoms persist despite standard therapy and can improve exercise tolerance.

    Medication for Acute Episodes of Stable Angina

    Bill should be prescribed sublingual nitroglycerin (0.3–0.6 mg) for acute anginal episodes. This nitrate works by dilating coronary arteries and reducing myocardial oxygen demand. He should be advised to take it at the onset of chest pain and repeat every 5 minutes for up to three doses if pain persists, then call emergency services.

    Medications to Improve Outcomes

    Though Bill’s LDL is within target, statin therapy (e.g., atorvastatin 20–40 mg daily) is recommended for secondary prevention in patients with established CAD, including stable angina, regardless of baseline LDL (Grundy et al., 2019). Additionally, low-dose aspirin (81 mg daily) is advised unless contraindicated, to reduce the risk of thrombotic cardiovascular events (Fihn et al., 2012).

    Drug Therapy Monitoring Plan

    Monitoring should include:

    • Blood pressure and heart rate (to avoid bradycardia or hypotension with beta-blockers)

    • Lipid profile every 4–12 weeks after statin initiation, then annually

    • Liver function tests for statins at baseline and as clinically indicated

    • Assessment of angina frequency, exercise tolerance, and nitroglycerin use

    • Electrocardiogram (ECG) as needed to monitor for ischemic changes

    Patient Education

    Bill should be educated on:

    • Recognizing and responding to anginal symptoms

    • Proper use of nitroglycerin, including storage and when to seek emergency help

    • Lifestyle modifications: diet rich in fruits, vegetables, whole grains; regular aerobic exercise; stress reduction

    • Importance of medication adherence

    • Need for regular follow-up to adjust therapy as needed

    References

    Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Blankenship, J. C., Dallas, A. P., … & Smith, S. C. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. Journal of the American College of Cardiology, 60(24), e44-e164. https://doi.org/10.1016/j.jacc.2012.07.013

    Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., … & Yeboah, J. (2019). 2018 AHA/ACC cholesterol clinical practice guideline. Circulation, 139(25), e1082–e1143. https://doi.org/10.1161/CIR.0000000000000625

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