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12/23/2002

Cardiac Groups Revise Angina Management Guidelines

Kate Traynor

Revised guidelines for the management of chronic stable angina call for the widespread use of angiotensin-converting-enzyme (ACE) inhibitors in patients with cardiovascular disease.1

This was among the more notable recommendations presented in the new American College of Cardiology and the American Heart Association guidelines; the 1999 guidelines had stated that the clinical effectiveness of ACE inhibitors had not been established in patients with stable angina. The new recommendation is that, in the absence of contraindications, all patients with coronary artery disease who also have diabetes mellitus or left ventricular systolic dysfunction receive an ACE inhibitor. Those with diabetes mellitus who do not have severe renal disease are deemed particularly good candidates for ACE-inhibitor therapy. According to the guidelines, treatment with an ACE inhibitor seems to greatly reduce the risk of diabetes-related complications of the eye and kidney and provides cardiac benefits.

Also identified to receive an ACE inhibitor are patients after a myocardial infarction (MI) or with coronary artery disease or other vascular disease.

Beta-blockers. A previous recommendation to use a beta-blocker after an MI was expanded in the revised guidelines to include patients with stable angina who have not had an MI. Beta-blockers, along with calcium antagonists, are described as the most effective agents for relieving cardiac ischemia in patients with angina.

Lipid-lowering agents. As in 1999, the guidelines strongly emphasize the use of lipid-lowering therapy to prevent MI and death in patients with stable angina and known or suspected coronary artery disease. Lipid-lowering recommendations are consistent with those made last year by the National Cholesterol Education Program-Adult Treatment Panel III, commonly referred to as ATP III (see July 15, 2001, AJHP News).

According to the guidelines, patients with stable angina, known or suspected coronary artery disease, and a low-density-lipoprotein (LDL) cholesterol level of 100-129 mg/dL should modify their lifestyle, receive drug therapy, or both to achieve an LDL cholesterol level of <100 mg/dL. Patients with an LDL cholesterol concentration of 3130 mg/dL should receive drug therapy to reduce the level to less than 100 mg/dL.

According to the revised guidelines, nicotinic or fibric acid therapy should be considered for patients with elevated blood triglycerides or a low high-density-lipoprotein cholesterol level. The guidelines note that, as in 1999, no firm evidence has been found to support the use of fish oils and garlic to reduce cholesterol levels or lower blood pressure.

Smoking cessation. Smoking-cessation interventions are addressed in a section of the guidelines devoted to reducing patients' risk of coronary events. The guidelines recommend the use of nicotine replacement therapy and bupropion to help smokers quit smoking. Because few physicians are adequately trained in smoking-cessation techniques, the guidelines note, priority should be given to identifying and utilizing allied health professionals who have such training.

Asymptomatic patients. Several sections in the guidelines examine the treatment of patients who have heart disease but lack symptoms of angina. In such patients, the use of ACE inhibitors, beta-blockers, and lipid-lowering therapy is recommended after an MI and is somewhat less strongly advised in the absence of an MI.

Out of favor. Combination estrogen–progestin hormone therapy, which until recently was commonly thought to provide cardiovascular benefits to postmenopausal women, is not recommended for women with coronary artery disease. The guidelines also state that no basis exists for the use of estrogen therapy to prevent or delay the progression of heart disease. Women who have a coronary event while using hormone therapy are advised by the guidelines to consider discontinuing the treatment.

No good evidence exists to show that antioxidant therapy in the form of vitamin C or E supplements can prevent or treat heart disease, according to the guidelines, which recommend that such supplementation should not be used for the sole purpose of reducing cardiovascular risk factors.

Accompanying the revised treatment recommendations is the acknowledgment that patients can find it difficult to adhere to complex and expensive drug regimens. The guidelines urge pharmacists and other health professionals to teach patients about their medications and help improve adherence to drug therapy.

  1. American College of Cardiology/American Heart Association. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (accessed [PDF] 2002 Dec 2).