1. Clinical Management of Chronic Stable Angina

2. Anti-ischemic strategies in stable CAD Medical therapyPCICABG Initial therapy Recurrent ischemia TMREECPSCS  Antianginal drug therapy (uptitrate/add new agents) Repeat revascularization (if possible) TMR = transmyocardial revascularization EECP = enhanced external counterpulsation SCS = spinal cord stimulation Gibbons RJ et al. ACC/AHA 2002 guidelines. http://www.acc.org/clinical/guidelines/stable/stable.pdf.

3. Older antianginal drugs: Pathophysiologic effects β-blockers DHP CCBs Non-DHP CCBs Long-acting nitrates Drug class Coronary blood flow Arterial pressure Venous return Myocardial contractility Heart rate CCB = calcium channel blocker DHP = dihydropyridine *Except amlodipine Boden WE et al. Clin Cardiol. 2001;24:73-9. Gibbons RJ et al. ACC/AHA 2002 guidelines. www.acc.org/clinical/guidelines/stable/stable.pdf Kerins DM et al. In: Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 10 th ed. O 2 DemandO 2 Supply / *

4. Older antianginal drugs: Clinical conditions that may limit use Drug class β-blockersNitrates Calcium channel blockers † Asthma Severe bradycardia AV block Severe depression Raynaud’s syndrome Sick sinus syndrome Severe aortic stenosis Hypertrophic obstructive cardiomyopathy Erectile dysfunction * AV block Bradycardia Heart failure Left ventricular dysfunction Sinus node dysfunction *Treated with PDE5 inhibitors † Nondihydropyridine CCBs Gibbons RJ et al. ACC/AHA 2002 guidelines. www.acc.org/clinical/guidelines/stable/stable.pdf

5. “Unmet needs” in antianginal therapy Despite medical therapy and/or revascularization, some patients continue to experience angina Current treatment options for recurrent angina are limited Consensus on role of newer treatments is pending How best to manage symptomatic patients?