Tailor treatment to the patient in stable angina.
According to the 2006 Health Survey for England, angina affects 8% of men and 3% of women aged 55-64 increasing to 14% and 8% respectively for those aged 65-74. It is important to reassure patients with clinically significant coronary artery disease, both symptomatic and asymptomatic, that for most lifestyle modification and optimal medical therapy will prove sufficient treatment. However, a minority of patients may also require intervention by stents or surgery. It is vital that patients with obvious precipitating factors that may promote or aggravate underlying coronary artery disease address these with lifestyle changes. Smoking should be stopped and a balanced diet and regular exercise encouraged. Advice should be given on factors that aggravate angina e.g. cold weather, heavy exercise and emotional stress. Advice about physical exertion and sexual activity should be included. A short-acting nitrate for angina prevention and treatment of episodes of angina is recommended. It should be used prophylactically in advance of any exertion. In terms of secondary prevention, basic therapy includes aspirin and a statin and antihypertensive agents for those with higher blood pressure. Optimal drug therapy consists of two anti-anginal drugs, such as a beta-blocker or calcium channel blocker as first-line treatment and in preference to other drug therapy unless there are side-effects or contraindications to these. Prognosis of coronary artery disease is strongly linked to the volume of underlying myocardial ischaemia and this cannot be determined simply by the level of symptoms. This should be explained to patients who should be offered further investigation if they wish and should certainly be encouraged in younger patients. Patients who have positive exercise tests require further investigation, usually by angiography. Unless a significant volume of myocardium (>10%) is at risk from ischaemia, there may be no prognostic benefit from revascularisation. However, even in patients in whom there is no significant burden of ischaemia, revascularisation can be justified if the patient remains highly symptomatic despite optimal medical therapy or is intolerant of maximal medical therapy.