TREATMENT OF CHRONIC STABLE ANGINA-PECTORIS

Patients with angina pectoris may be stratified into low- or high-risk categories on the basis of clinical findings and a careful workup, possibly including nuclear imaging of stress-induced abnormal perfusion or contractile patterns and coronary angiography. High risk patients may require revascularization by angioplasty or bypass surgery, whereas low-risk patients can be managed medically. It is important to consider the impact of various anti-ischemic drugs on the myocardial demand-supply equation. A recent study indicated that the combination of a beta blocker plus isosorbide mononitrate is more effective in increasing exercise duration than is either the combination of a beta blocker and a calcium antagonist or triple therapy. In patients with single-vessel disease, angioplasty has been shown to be more effective than medical therapy in relieving symptoms, but the incidence of restenosis and the associated costs are high. Surgery favorably affects mortality in patients with left main coronary artery disease or 3-vessel disease with left ventricular impairment. New evidence suggests that endothelial dysfunction may play a more important role in chronic stable angina pectoris than has been appreciated and that such dysfunction may be treated with nitrates.