The deficiencies of current medical therapy for the management of angina pectoris.

Abstract

The prime management need in angina pectoris is to abolish or to minimize pain. Nitrates, calcium antagonists and beta-blockers are indicated for this purpose but they are not a complete answer to the problem. Selection of therapy for individual patients is not guided scientifically and, at present, treatment of angina follows general protocols rather than a personalized approach based on the underlying patho-anatomy and physiology. Medical therapy offers palliation of the disease rather than a cure, although recent evidence raises possibilities that some anti-anginal therapy, notably the calcium antagonists, may favourably affect disease progression. Tachyphylaxis, dosing, unwanted effects, and optimal sequences and combinations of medical therapy are important clinical problems about which remarkably little is known. The greatest deficiency of current medical therapy, however, is that, despite the amelioration of angina, beneficial effects on mortality have not been established. Thus, for the foreseeable future non-pharmacological therapy in the form of surgery or angioplasty will dominate management of high-risk anginal patients. At present, it is only in unstable angina that there is evidence of prognostic benefit from medical therapy with aspirin and anticoagulants. In more stable forms of angina, medical versus surgical comparisons reflect 'old' drugs and strategies. The prospects of reducing death and infarction by medical therapy in anginal patients should be re-examined.