Angina Pectoris Guidelines

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

Lipid level management

In 2002, the committee of the National Cholesterol Education Program made the following modifications to the Adult Treatment Panel III (ATP III) guidelines. [1]

In high-risk patients, a serum low-density lipoprotein (LDL) cholesterol level of less than 100 mg/dL is the goal.

In very high-risk patients, an LDL cholesterol level goal of less than 70 mg/dL is a therapeutic option. Patients in the category of very high risk are those with established coronary artery disease (CAD) with one of the following: multiple major risk factors (especially diabetes), severe and poorly controlled risk factors (especially continued cigarette smoking), multiple risk factors of metabolic syndrome (especially high triglyceride levels [≥200 mg/dL] plus non-HDL cholesterol level [≥130 mg/dL] with low high-density lipoprotein (HDL) cholesterol level [

For moderately high-risk persons (2+ risk factors), the recommended LDL cholesterol level is less than 130 mg/dL, but an LDL cholesterol level of 100 mg/dL is a therapeutic option.

However, the 2013 American College of Cardiology and American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk abandoned the traditional LDL- and non-HDL–cholesterol targets. Physicians are no longer asked to treat patients with cardiovascular disease to below 100 mg/dL or the optional goal of below 70 mg/dL. Instead, the guidelines identify four groups of primary- and secondary-prevention patients in whom physicians should focus their efforts to reduce cardiovascular-disease events. Depending on the type of patient, physicians should choose the appropriate "intensity" of statin therapy to achieve relative reductions in LDL cholesterol. [50]

The clinical guidelines advise that for those with atherosclerotic cardiovascular disease, high-intensity statin therapy should be used to achieve at least a 50% reduction in LDL cholesterol unless otherwise contraindicated or when statin-associated adverse events are present. In these cases, clinicians should use a moderate-intensity statin. Similarly, for those with LDL-cholesterol levels above 190 mg/dL, a high-intensity statin should be used with the goal of achieving at least a 50% reduction in LDL-cholesterol levels. [50]

The American Association of Clinical Endocrinologists (AACE) and National Lipid Association (NLA) have declined to endorse the ACC/AHA guidelines. In particular, the AACE disagrees with the removal of the LDL targets and the idea that statin therapy alone is sufficient for all at-risk patients, noting that many who have multiple risk factors, including diabetes and established heart disease, will need additional therapies. [51, 52]

Medical Management

2012 joint guidelines from the American College of Cardiology Foundation (ACCF), AHA, American Association for Thoracic Surgery (AATS), Preventive Cardiovascular Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS) offer the followiing recommendations for medical management of stable ischemic heart disease [53]

Class I

Individualize patient education plans to optimize care and promote wellness that includes the following:

  • Review of all therapeutic options (Level of evidence: B)

  • Explanation of medication management and cardiovascular risk reduction strategies in a manner that respects the patient's level of understanding, reading comprehension, and ethnicity (Level of evidence: B)

  • Education on the importance of medication adherence for managing symptoms and retarding disease progression (Level of evidence C)

  • Encouragement to maintain recommended levels of daily physical activity (Level of evidence: C)

  • Self-monitoring skills and information on how to recognize worsening cardiovascular symptoms and how to take appropriate action (Level of evidence: C)

  • Education about the lifestyle factors that could influence prognosis, such as weight control, lipid management; blood pressure control; smoking cessation and avoidance of exposure to secondhand smoke; and lifestyle changes for patients with diabetes mellitus to supplement diabetes treatment goals and education (Level of evidence: C)

Treatment with aspirin 75-162 mg daily should be continued indefinitely in the absence of contraindications in patients with stable ischemic heart disease (SIHD). (Level of evidence: A) However, treatment with clopidogrel is reasonable when aspirin is contraindicated. (Level of evidence: B)

Angiotensin converting enzyme (ACE) inhibitors should be prescribed in all patients who also have hypertension, diabetes mellitus, left ventricular ejection fraction (LVEF) of 40% or less, or chronic kidney disease, unless contraindicated. (Level of evidence: A)

Angiotensin receptor blockers (ARBs) are recommended for patients who have indications for, but are intolerant of, ACE inhibitors. (Level of evidence: A)

Beta blockers should be prescribed as initial therapy for relief of symptoms. (Level of evidence: B) However, calcium channel blockers or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects. (Level of evidence: B)

Calcium channel blockers or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful. (Level of evidence: B)

Administer sublingual nitroglycerin or nitroglycerin spray for immediate relief of angina. (Level of evidence: B)

Class IIa

It is reasonable to educate patients about 1) adherence to a diet that is low in saturated fat, cholesterol, and trans fat; high in fresh fruits, whole grains, and vegetables; and reduced in sodium intake, with cultural and ethnic preferences incorporated (Level of evidence: B); and 2) common symptoms of stress and depression to minimize stress-related angina symptoms. (Level of evidence: C)

Class III

Dipyridamole is not recommended as antiplatelet therapy. (Level of evidence: B)

Estrogen therapy is not recommended in postmenopausal women to reduce cardiovascular risk or improve clinical outcomes. (Level of evidence: A)

Vitamin C, vitamin E, and beta-carotene supplementation are not recommended to reduce cardiovascular risk or improve clinical outcomes. (Level of evidence: A)

Treatment of elevated homocysteine with folate or vitamins B6 and B12 is not recommended to reduce cardiovascular risk or improve clinical outcomes. (Level of evidence: A)

Treatment with garlic, coenzyme Q10, selenium, or chromium is not recommended to reduce cardiovascular risk or improve clinical outcomes. (Level of evidence:C)

Acupuncture should not be used for the purpose of improving symptoms or reducing cardiovascular risk (Level of evidence: C)

In a 2014 focused update, the ACC/AHA/AATS/PCNA/SCAI/STS modified its recommendations regarding the potential benefit of chelation therapy for reducing cardiovascular events from not beneficial (Class III, level of evidence: C) to uncertain benefit (Class IIb, level of evidence: B). [54]

The 2013 European Society of Cardiology (ESC) includes the following recommendations. [55]

Class I

For optimal medical treatment, use at least one drug for angina/ischemia relief plus drugs for event prevention. (Level of evidence: C)

For angina/ischemia relief: use short-acting nitrates (Level of evidence: B); first-line treatment is with beta-blockers and/or calcium channel blockers to control heart rate and symptoms. (Level of evidence: A)

For event prevention: Use low-dose aspirin daily (Level of evidence: A); clopidogrel is indicated as an alternative in case of aspirin intolerance (Level of evidence: B). Statins are indicated for all patients with stable coronory artery disease. (Level of evidence: A). Use ACE inhibitors (or ARBs) if other conditions  are present (eg, heart failure, hypertension, or diabetes). (Level of evidence: A)

Class IIa

For angina/ischemia relief (second-line treatment): Add long-acting nitrates, ivabradine, nicorandil, or ranolazine, according to  the patient's heart rate, blood pressure, and tolerance (Level of evidence: C); in asymptomatic patients with large areas of ischemia (>10%) consider beta-blockers. (Level of evidence: B)

Revascularization Therapy

The 2012 ACC/AHA/AATS/PCNA/SCAI/STS guideline recommendations for surgical management include the following. [53]

Class I

Coronary artery bypass graft (CABG) is recommended to improve survival for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis. (Level of evidence: B)

Class IIa

To improve survival, percutaneous coronary intervention (PCI) is reasonable as an alternative to CABG in selected stable patients with significant (≥50% diameter stenosis) unprotected left main CAD with anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome.(Level of evidence: B)

Class III

PCI should not be performed in stable patients with significant (≥50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG. (Level of evidence: B)

In joint 2014 guidelines for myocardial revascularization, the ESC and the European Association for Cardio-Thoracic Surgery (EACTS) indications (all Class I) for revascularization in patients with stable angina are below. [56]

For prognosis:

  • Left main disease with stenosis of over 50% (Level of evidence: A)
  • Any proximal left anterior descending (LAD) artery stenosis above 50% (Level of evidence: A)
  • Two-vessel or three-vessel disease with stenosis above 50% with impaired LV function (LVEF <40%) (Level of evidence: A)
  • Large area of ischemia (>10% LV) (Level of evidence: B) 
  • Single remaining patent coronary artery with stenosis of over 50% (Level of evidence: C)

For symptom relief: Any coronary stenosis greater than 50% in the presence of limiting angina unresponsive to medical therapy (Level of evidence: A)

Duration of Dual Antiplatelet Therapy

In 2016, the ACC/AHA released updated guidelines on duration of dual antiplatelet therapy (DAPT) in patients with CAD. In this focused update, the term and acronym DAPT is used to specifically to refer to combination antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor). Key recommendations for SIHD treated with PCI or CABG include those below. [57]

Class I

In patients with SIHD treated with DAPT after bare metal stent (BMS) implantation, use P2Y12 inhibitor therapy with clopidogrel for at least 1 month. (Level of evidence: A)

In patients with SIHD treated with DAPT after drug-eluting stent (DES) implantation, use P2Y12 inhibitor therapy with clopidogrel for at least 6 months. (Level of evidence: B-R)

The recommended daily dose of aspirin is 81 mg (range, 75 mg to 100 mg). (Level of evidence: B-NR)

Class IIb

It may be reasonable to continute DAPT with clopidogrel for longer than 1 month for patients with BMS or longer than 6 months for patients treated with DES if DAPT has been tolerated without a bleeding complication and the patient is not at high bleeding risk. (Level of evidence: A)

It may be reasonable to discontinue P2Y12 inhibitor therapy after 3 months in patients treated with DAPT after DES implantation who develop a high risk of bleeding or develop significant overt bleeding. (Level of evidence: C-LD)

It may be reasonable to treat with DAPT (with clopidogrel initiated early postoperatively) for 12 months after CABG to improve vein graft patency. (Level of evidence: B-NR)

Class III

In patients with SIHD without prior history of acute ACS, coronary stent implantation, or recent (within 12 months) CABG, treatment with DAPT is not beneficial. (Level of evidence: B-NR)