Stable angina
A chronic coronary syndrome with episodes of retrosternal pain or discomfort on physical exertion, emotional stress, lasting 1–10 minutes, relieved by rest or nitroglycerin. ESC 2024 sets two-layered therapy: antianginal drugs for symptoms (β-blockers, calcium antagonists, long-acting nitrates, ivabradine, ranolazine) and prognosis-modifying agents (aspirin, statins, ACE inhibitors in HF/diabetes). With limited response to medical therapy or multivessel disease, revascularization (PCI or CABG) is offered.
ICD-10 I20.84 drugs
Also known as: Chronic coronary syndrome, Effort angina
Drugs used for this condition
- AIsosorbide mononitrateFirst line · Long-acting organic nitrateFirst-line for long-term prevention of stable angina attacks per ESC 2024 alongside β-blockers and calcium channel blockers. Dose 40–60 mg once daily in the morning in extended-release form. Reduces preload and improves coronary flow. Does not affect mortality or cardiovascular outcomes – a symptomatic agent. For acute attacks, sublingual nitroglycerin is used.
- ANitroglycerinFirst line · Organic nitrateSublingual nitroglycerin 0.3–0.6 mg or spray is the drug of choice for terminating a stable angina episode. Onset is 1–3 minutes, duration 20–30 minutes. AHA/ACC 2023 and ESC 2024 recommend that every patient with stable CAD carry a sublingual formulation. If pain persists 5 minutes after the first dose, call emergency services – the picture may represent acute coronary syndrome. Prophylactic use 5–10 minutes before anticipated exertion is acceptable.
- BIvabradineSecond line · Selective If channel inhibitor of the sinoatrial nodeUsed in stable angina in patients with sinus rhythm and resting HR ≥70 bpm intolerant to or inadequately controlled on β-blockers. SIGNIFY in non-HF patients raised cardiovascular death and non-fatal MI by 18% – since then, angina-only indications are restricted to patients without alternatives.
- BRanolazineSecond line · Antianginal – late sodium current inhibitorSecond-line for stable angina per ESC 2024 in patients with inadequate symptom control on β-blockers and/or calcium antagonists, or with intolerance. Dose 375–750 mg twice daily. Particularly useful in patients with bradycardia, hypotension, or heart failure where β-blockers and nitrates are limited. ERICA showed 30% reduction in angina episodes and improved exercise tolerance.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit