Contemporary approaches in medical management of patients with stable coronary artery disease.

CAD continues to be the principal cause of mortality in the United States, and the largest group of patients with CAD are those with stable angina. Among this group of patients, the most common manifestation of CAD is presence of transient episodes of myocardial ischemia. The presence of transient ischemia and not the severity of angina has been found to be associated with poor clinical outcome in patients with stable CAD. As part of a global treatment strategy for patients with stable CAD, changes in lifestyle and modification of coronary risk factors should be emphasized as an integral part of treatment. Conventional antianginal therapy is quite effective in controlling anginal attacks. Currently, several drugs and therapeutic strategies are available for the treatment of patients with angina (see Table 5). Nitrates are highly effective antianginal drugs with complex beneficial actions in patients with CAD, but their usefulness is limited by development of tolerance during long-term use. When clinically indicated, the use of nitrates should be supplemented with another longer-acting antianginal drug, such as a beta-blocker or a calcium channel blocker. Based on the available data, beta-blockers, when tolerated, seem to be the most effective antianginal drugs for most patients with stable CAD. Beta-blockers are also the most effective anti-ischemic drugs that reduce the magnitude of myocardial ischemia detected during routine daily activities. Calcium channel blockers are also effective vasodilators and good antianginal drugs. The clinician should become familiar with the different actions that this heterogeneous group of drugs has on the heart and vessels. This knowledge allows the clinician to choose the appropriate combination of different antianginal drugs for patients on an individualized basis. It is also critical to develop the treatment strategy by carefully taking into account other associated medical conditions that are frequently encountered in patients with CAD.