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In this article:
Treatment for chronic
angina has two major goals. The first is to prevent heart
attacks and death. This increases the "quantity," or length,
of your life. The other is to reduce your number of angina
attacks. Fewer attacks mean you may be able to begin to resume some
of your regular daily activities. This improves the "quality" of
your life.1
Medications, non-surgical treatments, and perhaps even major surgery, will be part of your treatment plan. Your doctor has received special training to prescribe medications for your heart condition. She or he will choose medications that best fit your symptoms and medical history.
Your doctor may also consult published guidelines for angina treatment. The guidelines, last published in 1999,1 were developed by a group of doctors who are highly experienced at treating chronic angina. These doctors are members of the American College of Cardiology, the American Heart Association, the American College of Physicians, and the American Society of Internal Medicine.
The guidelines suggest that short-acting nitroglycerin, a type of nitrate, given as a tablet under the tongue or as an oral spray be prescribed to all patients to help relieve sudden painful angina attacks. For long-term treatment and prevention, the guidelines indicate there is ample research to show that beta-blockers help prevent death after heart attacks. Therefore, to help reduce both heart attack risk and the onset of sudden attacks, angina experts have made beta-blockers their first choice.
Sometimes, beta-blockers may cause side effects or may not adequately control angina attacks. The next choice the experts suggest is a calcium channel blocker. These medications are preferred to long-acting nitrates because some patients may build up a tolerance to the effects of nitrates over time, making them progressively less effective. If calcium channel blockers can't be used, possibly because of bothersome side effects, or don't provide enough relief, doctors may then prescribe long-acting nitrates. These medications may be used alone or in combination.
Remember that each patient responds differently to treatment, so what your doctor chooses for you may not be the same as another person with angina. Also, be sure to ask your doctor and pharmacist about possible side effects and drug interactions that any medications might cause.
Drugs for angina pain control
Current angina drugs work by either increasing blood flow to the heart or by decreasing the heart's workload, especially during physical activity or emotional stress. When the heart is working harder, it needs adequate amounts of oxygen-rich blood to keep working effectively without causing angina attacks. By helping the heart in these ways, both methods may result in less angina pain.
A number of anti-angina drugs are prescribed in the United States. They fall within three major drug classes—groupings of medications that have similar functions and side effects—and include beta-blockers, calcium channel blockers, and nitrates. If you aren't sure what class of prescription medicines you're taking, ask your doctor or pharmacist.
The information below provides an overview of how each drug works, common side effects, and other details.
Beta-blockers
The brain coordinates all your body's functions. It does this by sending signals through nerves to the areas waiting to respond. Like small monitors, special receptors in the tissue receive the message and transmit the signal to an organ, for example, or a muscle. Once the message is received, the organ knows to function in a certain way.
Some receptors in the heart are called beta-receptors. Beta-receptors receive the signal from the brain to make the heart beat faster and stronger, such as during exercise or when you are tense. If you have coronary artery disease (CAD) and increase the work of your heart, you know that an angina attack may be possible.
Beta-blockers work just the way their name implies: They "block" beta-receptors in the heart from receiving the message to beat harder and faster. The heart may not then require extra oxygen, because its workload is eased.
Your doctor may prescribe a beta-blocker for you to take daily. But if you have a history of a very slow heart rate, certain electrical problems in the heart, asthma, or severe depression, your doctor may choose another class of medication for you. Also, people with diabetes who take insulin may need to use beta-blockers carefully. These drugs may hide signs that their blood sugar is dangerously low. Careful blood sugar monitoring may help avoid this concern.
Beta-blockers may cause side effects. Some of the more frequent are fatigue (sometimes severe), lack of energy, difficulty sleeping, nightmares, and sexual problems in men and women. Some beta-blockers may be more likely than others to cause these effects.
If you have one or more of these side effects, your daily life may still be hindered even though your angina is improved. If so, let your doctor know. Sometimes, finding just the right drug for you can be a matter of trial and error.
Calcium channel blockers
You've been told all your life that calcium makes strong bones. It also makes for a strong heart muscle. Calcium is extremely important for the heart's pumping action. Special channels for calcium let this mineral flow into heart muscle cells (called myocytes) to help the heart pump and work.
Blood vessel walls also contain calcium channels. But calcium flowing into the vessels isn't always such a good thing; it makes them tighten up, and can decrease the width of the blood vessel. Less blood flows through, possibly increasing your risk for angina pain or discomfort.
All calcium channel blockers (also called calcium antagonists) work to block the flow of calcium through the calcium channels. However, some calcium channel blockers work more in one area of the cardiovascular system than others. For example, some work to block the flow of calcium through the calcium channels of blood vessels. The vessels then relax and widen, increasing blood flow and making it easier for the heart to pump blood to the rest of the body. Other calcium channel blockers decrease the force of the pumping action of the heart. Others decrease heart rate. Altogether, calcium channel blockers may reduce the heart's workload so that it doesn't need as much oxygen-rich blood to keep up with the demand.
Calcium channel blockers are taken daily over the long-term. Your doctor will decide which calcium channel blocker is best for you. If you have severe heart failure or certain types of abnormal heart rates, your doctor may not want to choose this class of medication for you.
More common side effects of calcium channel blockers may include lowered blood pressure, swelling of the lower legs (edema), and constipation. Other reported side effects include headache, flushing, and dizziness. As with any drug, let your doctor know about any side effect you may experience.
Nitrates
Nitrates are drugs that help blood vessels relax. If the vessel is more relaxed, then the lumen is wider, allowing more blood to flow through. It's as simple as a four-lane tunnel being able to handle more cars than a two-lane tunnel. More oxygen-rich blood flowing through the arteries of the heart brings the heart more fuel to make energy. As you would expect, more fuel for the heart may mean fewer angina attacks for you.
The best-known nitrate is nitroglycerin, available in both short-acting and long-acting forms. The short-acting form may be the first drug your doctor prescribes for quick relief of your angina attacks. When you feel an angina attack starting, you'll place one tablet under your tongue and let it dissolve. Or, you may have been prescribed a nitroglycerin spray that is sprayed into your mouth. Your doctor will tell you how frequently and how many doses you should take, and what to do if the nitroglycerin isn't working.
For long-term prevention of angina pain, your doctor may prescribe other drugs (a beta-blocker or a calcium channel blocker, for example) before giving you a long-acting form of nitrates. These nitrates are only taken once or twice a day as a tablet or skin patch.
Long-acting nitrates may lose the ability to treat your angina over the long term. This effect is called tolerance. To avoid this, only so many doses are given in a 24-hour period. Your doctor may tell you to only take one tablet a day, or if you have a skin patch, you may be told to put the patch on in the morning and take it off in the evening. This short "vacation" from nitrates helps you avoid nitrate tolerance.
The most common side effect of both short- and long-acting nitrates is headache. If you use the long-acting form of nitroglycerin, then headaches may eventually go away as your body adjusts to the drug. You may feel warmth and redness in the face (called flushing). Some people may get dizzy because of lower blood pressure. Also, the short-acting tablets placed under the tongue may cause bad breath for some patients.
Drug interactions can be fairly common. Even some dietary supplements may interact with some medications. Since many patients with angina can be on multiple medications, it is important to speak with your doctor or pharmacist and inform them of all the medications you are taking.
One potentially serious drug interaction with nitroglycerin is worthy of note. Viagra® (sildenafil), the drug used to treat male impotence (also called erectile dysfunction) can decrease blood pressure. If you have also taken nitroglycerin, the drop in blood pressure may be dramatic. The manufacturer of Viagra® advises people not to mix these two medications.2
Drugs for cutting heart attack risk
Though beta-blockers, calcium channel blockers, and nitrates can help control the pain or discomfort of angina, research shows that beta-blockers have the added benefit of decreasing your chance of death after a heart attack.
What about preventing a heart attack before it happens? Two classes of drugs may help prevent attacks, along with doctor-approved exercise and a heart-healthy diet. They're not for everybody, though. Ask your doctor before trying them.
Aspirin. This medication has been around for more than 100 years and is a common remedy for headaches and other body pain. But aspirin can also decrease the chance of having a heart attack by as much as one-third.1 How? By making platelets—a blood cell with a sticky, adhesive quality—less sticky. When platelets can't easily stick to plaque, it is less likely for a blood clot (also called a thrombus) to form in the coronary arteries. This is called an anti-thrombotic effect. If a blood clot forms in the coronary arteries, a portion of the heart may not receive enough oxygen-rich blood and die, leading to a heart attack.
If you have angina and CAD, your doctor will tell you if you need to take aspirin. Even though you can buy aspirin without a prescription, be sure you have your doctor's OK first. Some people can't take aspirin, such as those with a history of stomach problems like ulcers, or an aspirin allergy. If your doctor believes you need an anti-thrombotic but you are unable to take aspirin, clopidogrel, or ticlopidine may be other alternatives.
Anti-cholesterol drugs. The main culprit of angina and CAD is the unwanted buildup of fats inside the coronary arteries, largely because of high levels of LDL, the "bad cholesterol," in the blood. This leads to a narrowing of the lumen that oxygen-rich blood flows through. Without enough oxygen, the heart will not receive enough fuel to continue working well and angina pain or discomfort may result.
A group of drugs nicknamed statins work to lower levels of bad cholesterol (LDL). Like aspirin, statins decrease the chance of having a heart attack by about one-third.1 Statins work because they may slow the rate of plaque buildup, may make plaques more stable against breakage, and may even help make plaques smaller. Other drugs that also may help decrease LDL by working in a different way from statins. Ask your doctor for more information.
Statins can interact with some other medications. Be sure your doctor and pharmacist know about all the medications you're taking. Also, if statin levels are too high in the blood, some people may develop muscle damage. If you are taking a statin and notice muscle pain, soreness, or unusual weakness, let your doctor know right away.
Quality of life
Medications can help control angina and prevent an early death from a heart attack. But the more medications you take, the more side effects may bother you. Even though your angina is better, these side effects may put a crimp in your lifestyle and keep you from enjoying your daily routine.
Even so, taking your prescriptions as ordered by your doctor is very important. Constant drug levels must be present in the body for a medication to work properly and control symptoms. The less angina you experience, the better your quality of life may become. If you are unable to take your medications for any reason, or if you think you may be having a possible side effect, let your doctor know right away.
Achieving a good quality of life is another treatment goal you and your doctor should discuss. To learn more, visit the Quality of Life section of LifeHeart.com.
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The surgery called a coronary artery bypass graft aims to increase the flow of oxygen-rich blood to the heart. True or False?
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Sources
1. "American College of Cardiology/American Heart Association/American College of Physicians/American Society of Internal Medicine Guidelines for the Management of Patients with Chronic Stable Angina." Journal of the American College of Cardiology, 1999, Vol. 33, No. 7. 2092-2197.
PubMed
2. Pfizer USA. Viagra® Package Insert. January 2000. Physicians' Desk Reference. 55th ed., 2001. 2354-2357.
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