Management of Microvascular Angina Pectoris

Gaetano A. Lanza; Rossella Parrinello; Stefano Figliozzi


Am J Cardiovasc Drugs. 2014;14(1):31-40. 

In This Article

Comprehensive Approach to Treatment of MVA

In patients with MVA, the response to medical treatment is rather unpredictable and often disappointing. This is likely mainly due to the significant heterogeneity of the mechanisms of angina in these patients. An improvement in efficacy of therapy might derive from tailoring treatment to the underlying mechanism(s), but a full pathogenic assessment of individual patients is difficult to achieve in clinical practice. Accordingly, treatment of MVA is largely empiric and requires an optimal interaction between the caring physician and the patient in the attempt to achieve optimal symptom control.

A schematic stepwise approach to treatment of patients with stable MVA, which reflects our current practice, is summarized in Fig. 3. First-line drug therapy is represented by β-blockers or non-dihydropyridine calcium antagonists, while a combination of a β-blocker and a dihydropyridine (or also a non-dihydropyridine) calcium antagonist should constitute the second step when single drugs fail. Ivabradine can be added when β-blockers are poorly tolerated, whereas ranolazine should now probably constitute the third pharmacological step.

Figure 3.

Stepwise therapeutic approach to patients with microvascular angina. ACE angiotensin-converting enzyme

Although long-acting nitrates can be added at any time, there is scarce evidence of their actual efficacy. Other drugs with potential anti-ischemic effects can further be selected, in addition to or as substitution for previous drugs based on an individual assessment of patients.

SCS or analgesic drugs may represent the last resource in patients with refractory MVA, whereas the risk/benefit ratio of EECP needs further assessment in these patients. Finally, rehabilitation exercise programs and/or psychological treatments, according to the patient's characteristics, might also be helpful to improve symptoms and exercise tolerance in refractory MVA. While strict control of cardiovascular risk factors, when present, should obviously always be part of the management of patients, reassurance and a sympathetic approach from cardiologists are also crucial measures in improving chest pain and compliance with treatment, as well as obtaining a more positive attitude from the patient towards her/his symptoms.