First Line Drugs
- ACETYLSALICYLIC ACID (N02BA01)
- GLYCERYL TRINITRATE (C01DA02)
- METOPROLOL (C07AB02)
Second Line Drugs
- VERAPAMIL (C08DA01)
- ACETAMINOPHEN (PARACETAMOL) (N02BE01)
- FELODIPINE (C08CA02)
1. Secondary prophylactic treatment for all patients
ASA, enteric coated 325 mg, once daily $0.01/day
2. Initial treatment of symptoms with nitrates
nitroglycerin tablets 0.3-0.6 mg, sublingual prn $0.03/dose
or nitroglycerin spray 0.4 mg, sublingual prn $0.06/dose
3. All patients who require regular symptomatic treatment should receive a beta-blocker.
propranolol 40-160 mg, bid $0.07-0.23/day
or metoprolol 25-100 mg, bid $0.12-0.45/day
or nadolol 20-240 mg, once daily $0.12-0.66/day
1. If patient has contraindications to beta-blockers, such as reactive airway disease, or experiences side effects from beta-blockers
verapamil 80 mg, tid $0.82/day
or verapamil SR 240 mg, once daily $0.87/day
2. If patient is intolerant of both beta-blockers and verapamil
i. Long-acting nitrates to be used for a maximum of 12 h/day. Nitrates should be used during high-risk periods, e.g., times when angina is common and overnight into the early hours of the morning
isosorbide dinitrate 30-60 mg, tid with eccentric dosing $0.10-0.21/day
nitroglycerin paste 1-5 cm tid with eccentric dosing $0.19/g
or nitroglycerin transdermal 0.4 mg/h; apply in morning; remove 12 h later $0.64/patch
or isosorbide mononitrate 20 mg, in morning and afternoon, 7 h apart $0.95/day
ii. Calcium channel blockers
diltiazem 30-120 mg, tid to qid $0.62-3.44/day
or felodipine 5-10 mg, once daily $0.66-0.99/day
or nifedipine XL 30-60 mg, once daily $0.93-1.46/day
or amlodipine 5-10 mg, once daily $1.28-1.90/day
-In patients with diabetes and angina, who are unable to use beta-blockers, calcium channel blockers may also be the first-line drug therapy.
-For patients with beta-blocker induced symptomatic bradycardia or with low HDL cholesterol, acebutolol may be the beta-blocker of choice.
-If combination therapy is necessary, the following appear to have additive or synergistic effects: in patients taking beta-blockers, add a dihydropyridine; in patients taking beta-blockers who cannot tolerate dihydropyridines, add a long-acting nitrate; in patients taking verapamil, add a long-acting nitrate; in patients taking long-acting nitrates, add any calcium channel blocker.
-Use of short-acting nifedipine in patients with coronary artery disease may be associated with increased mortality and should be avoided. Trials are currently underway to evaluate the safety of long-acting dihydropyridines when used in patients with ischemic heart disease. Until they are completed, this class of calcium channel blocker should be reserved for patients not responding to other agents.
-An example of eccentric dosing is 8 am, noon and 4 pm
-Low doses of ASA (80 mg/day) are also effective and are used in some patients who cannot tolerate higher doses.