Management of Coronary Artery Disease and Chronic Stable Angina

Yesenia Camero, PharmD, BCPS; Jinwi Ghogomu, PharmD, BCPS, CPh


US Pharmacist. 2017;42(2):27-31. 

In This Article


Beta-blockers reduce myocardial oxygen consumption through a decrease in heart rate and myocardial contractility. This reduction in heart rate allows for greater time spent in diastole, thereby promoting greater coronary perfusion and myocardial oxygen supply. This medication class is recommended to be initiated and continued for 3 years in patients with normal left ventricular function after an MI. For patients with left ventricular dysfunction, beta-blocker therapy should be continued indefinitely. Particular attention should be paid to the beta-blocker used in this patient population. Carvedilol, metoprolol succinate, and bisoprolol have been shown to reduce the risk of death in patients with chronic systolic heart failure (HF). This survival benefit does not extend to patients with chronic stable angina in the absence of MI or HF. However, beta-blockers should be used as first-line therapy with the goals of reducing the frequency and severity of angina and improving exercise capacity and quality of life.[6]

ACE Inhibitors and Angiotensin Receptor Blockers (ARBs)

A body of evidence suggests that ACE inhibitors, in addition to their established efficacy in the management of hypertension, have benefits extending beyond their BP-lowering effects. The main mechanism by which ACE inhibitors work is a reduction of angiotensin II and an increase in bradykinin. Angiotensin II causes vasoconstrictive effects that increase oxidative stress, promote inflammation and thrombosis, damage the endothelium, and worsen atherosclerosis. Bradykinin promotes vasodilation, which counteracts the harmful effects of angiotensin II.[12]

Clinical trials have consistently shown that ACE inhibitors reduce the risk of morbidity and mortality from HF, stroke, MI, diabetes, and renal impairment. ACE inhibitors may also offer a protective effect for patients with SIHD. A clinical trial conducted in SIHD patients with no clinical evidence of HF showed a reduction in the composite endpoint of cardiovascular death.[13] Therefore, it is recommended that all patients with SIHD who also have one or more risk factors, such as hypertension, diabetes, HF, or chronic kidney disease, be prescribed an ACE inhibitor. ARBs are recommended as an alternative for patients who cannot tolerate ACE inhibitors.