- Angina results from ischemia due to an imbalance between myocardial O2 requirements and myocardial O2 supply.
- This imbalance may occur secondary to:
- hemodynamic demands (HR and BP),
- myocardial blood flow, or
- cardiomyocyte energetics
- This imbalance may occur secondary to:
- First-line antianginals exert their effects through modification of hemodynamic mechanisms of ischemia.
- ==BBs should be prescribed as initial therapy== (Class 1)
- If BBs contraindicated or angina is refractory (adjunct to BBs),
- CCBs (Class 1) or
- long-acting nitrates (Class 1), which produce coronary vasodilation and ↓ BP
- Ranolazine (Class 2a)
- Ivabradine lowers HR
- Renin-angiotensin-aldosterone system inhibitors (RAASi) such as valsartan work through the renin-angiotensin system to reduce BP.
- As above, if BBs are contraindicated, leads to unacceptable side effects, or is ineffective, could try Ranolazine (Class 2a)
- Ranolazine’s antianginal effects are unique in that they are independent of significant changes to the HR–BP product
- Ranolazine does not alter myocardial blood flow.
- Recommended for patients with stable ischemic heart disease with continued symptoms despite the use of BBs or who cannot use acceptable doses of BBs (Class 2a).