Novel drugs for treating angina

Angina is the pain caused by myocardial ischaemia, usually as a result of obstructive coronary artery disease. Although angina typically presents as chest pain on exertion, patients can also present with atypical symptoms such as shortness of breath without pain. Guidelines1 2 recommend initial treatment with one or two antianginal drugs, plus aspirin, and a statin for secondary prevention of cardiovascular disease. If symptoms are not adequately controlled, coronary revascularisation by percutaneous coronary intervention or coronary artery bypass surgery is often effective.1 2

The antianginal drugs recommended for initial treatment are β blockers and calcium channel blockers, which reduce myocardial ischaemia by heart rate reduction and vasodilatory mechanisms, respectively. Either or both of these drug classes should be prescribed, together with a short acting nitrate for prompt alleviation of angina attacks (figure⇓) However, if these drugs are not tolerated, are contraindicated, or fail to correct symptoms, alternative antianginals are available, such as oral nitrates and newer antianginal drugs, which are the subject of this review. Although oral nitrates have been used for many years to treat stable angina, the National Institute for Health and Care Excellence concluded that evidence related to their efficacy was insufficient and hence advised that oral nitrates should be used as second line therapy after β blockers and calcium channel blockers. NICE also concluded that evidence was insufficient to make a firm recommendation about the choice of second line antianginals, which we present here in alphabetical order.