Chapter 1 Chronic Stable Anginacoronary arteries to assess for presence of ventricu-
lar hypertrophy and/or diastolic dysfunction. (Level
of Evidence: C)
Class IIb
1 Intracoronary acetylcholine is reasonable during
coronary arteriography, if the arteriogram is visually
normal, to assess endothelium dependent coronary
fl ow reserve, and exclude vasospasm. (Level of Evi-
dence: C)
2 Intracoronary ultrasound, coronary fl ow reserve,
or fractional fl ow reserve are reasonable measure-
ments to exclude missed obstructive lesions, if
angiographic appearances are suggestive of
a non-obstructive lesion rather than completely
normal, and stress imaging techniques identify an
extensive area of ischaemia. (Level of Evidence: C)
Treatment
A. Pharmacologic therapy
Recommendations for pharmacotherapy to prevent
MI and death and to reduce symptoms
Class I
1 Aspirin should be started at 75 to 162 mg per day
(75 mg per day in ESC guideline) and continued
indefi nitely in all patients unless contraindicated.
(Level of Evidence: A)
2 Beta-blockers as initial therapy is recommended
to reduce symptoms in the absence of contraindica-
tions in patients with prior MI (Level of Evidence: A)
or without prior MI. (Level of Evidence: B)
Test the effects of a beta-1 blocker, and titrate to full
dose; consider the need for 24 h protection against
ischemia. (Level of Evidence: A) (Table 1.12).
3 It is benefi cial to start and continue beta-blocker
therapy indefi nitely in all patients who have had MI,
acute coronary syndrome, or left ventricular dys-
function with or without heart failure symptoms,
unless contraindicated. (Level of Evidence: A)
4 ACE inhibitors should be started and continued
indefi nitely in all patients with left ventricular ejec-
tion fraction less than or equal to 40% and in those
with hypertension, diabetes, or chronic kidney disease
unless contraindicated. (Level of Evidence: A)
5 ACE inhibitors should be started and continued
indefi nitely in patients who are not lower risk (lower
risk defi ned as those with normal left ventricular ejec-
tion fraction in whom cardiovascular risk factors are
well controlled and revascularization has been per-
formed), unless contraindicated. (Level of Evidence: B)Table 1.12 Nitroglycerin and nitrates in angina
Compound Route Dose Duration of effect
Nitroglycerin Sublingual tablets 0.3–0.6 mg up to 1.5 mg 11 / 2 –7 min
Spray 0.4 mg as needed Similar to sublingual tablets
Ointment 2% 6 × 6 in., 15 × 15 cm 7.5–40 mg Effect up to 7 h
Transdermal 0.2–0.8 mg/h every 12 h 8–12 h during intermittent therapy
Oral sustained release 2.5–13 mg 4–8 h
Buccal 1–3 mg 3 times daily 3–5 h
Intravenous 5–200 mcg/min Tolerance in 7–8 h
Isosorbide dinitrate Sublingual 2.5–15 mg Up to 60 min
Oral 5–80 mg, 2–3 times daily Up to 8 h
Spray 1.25 mg daily 2–3 min
Chewable 5 mg 2–2^1 / 2 h
Oral slow release 40 mg 1–2 daily Up to 8 h
Intravenous 1.25–5.0 mg/h Tolerance in 7–8 h
Ointment 100 mg/24 h Not effective
Isosorbide mononitrate Oral 20 mg twice daily 12–24 h
60–240 mg once daily
Pentaerythritol tetranitrate Sublingual 10 mg as needed Not known
Erythritol tetranitrate Sublingual 5–10 mg as needed Not known
Oral 10–30 3 times daily Not known