Treating Stable Angina

Invasive therapy, or non-invasive, medical treatment?

Stable angina describes symptoms associated with coronary artery disease (CAD). Coronary artery disease is caused by atherosclerosis, a condition where fatty deposits called plaques build up inside your arteries. 

Stable angina symptoms are produced by stable, non-ruptured plaques. Stable plaques have a lower risk of rupturing or breaking free, which is an event that can lead to a heart attack.

Because the plaque is not changing or is changing only gradually, it produces predictable symptoms. These are usually limited to chest discomfort.

This article looks at stable angina and its treatment.

Woman with hands over her chest

fstop123 / Getty Images

The Goals of Treating Stable Angina

There are three distinct goals for treatment of stable angina:

  • To eliminate or greatly diminish the symptoms.
  • To slow the progression of the atherosclerotic disease that is producing plaques.
  • To prevent the onset of more serious cardiac problems. This includes acute coronary syndrome (ACS)heart failure, and death.

The treatment, whether invasive or non-invasive, should optimize the chances of achieving all three of these goals.

Invasive vs. Non-Invasive Treatment

The invasive approach to stable angina is to remove blockages in the coronary arteries. This can be done a few different ways, including:

Clinical studies have shown that invasive treatment isn't always better than non-invasive treatment. Drug therapy and lifestyle changes can often produce outcomes that are as good as or better than surgery or stenting.

Most experts now recommend beginning with the non-invasive approach when treating stable angina. This "medical therapy first" approach reflects the new way of thinking about CAD.

There are two circumstances in which invasive treatment ought to be strongly considered, however. Invasive treatment may be better for:

  • People whose angina cannot be adequately controlled with medical therapy.
  • People who have blockages in certain coronary arteries where the outcome with medical therapy alone has been demonstrated to be worse than with invasive treatment. 

This latter category includes:

  • People who have blockages in the left main coronary artery
  • People with three-vessel disease
  • People who have disease in the left anterior descending artery along with disease in at least one other coronary artery

For most people with stable angina, however, non-invasive medical treatment is the preferred option. 

Non-Invasive Treatment for Stable Angina

Lifestyle changes and drug therapy are both important ways to treat stable angina. This combination of treatments can help reduce symptoms, prevent ACS, and improve survival in people with stable angina.

Invasive treatment also needs to be combined with lifestyle changes.

Medical Treatment to Get Rid of Angina

Four different types of drugs are commonly used to relieve stable angina symptoms. Most people with this condition will receive prescriptions for two or more of these kinds of drugs:

  • Beta-blockers: Beta-blockers reduce the effect of adrenaline on the heart muscle. This slows the heart rate and the force of heart muscle contraction. In this way, beta blockers reduce the oxygen demand of the heart. These drugs also improve survival in patients who have had a previous heart attack. They should be used in anyone who has stable angina. 
  • Calcium blockers: Calcium blockers reduce the influx of calcium into the heart muscle and into the smooth muscle of the blood vessels. This dilates the blood vessels, lowers heart rate, and reduces the forcefulness of the heartbeat. These actions help lower the oxygen demand of the heart. 
  • Nitrates: Nitrates cause dilation of blood vessels. This reduces stress on the heart muscle, which reduces the demand for oxygen. 
  • Ranexa (ranolazine): Ranexa is a new type of anti-angina drug that appears to work by blocking what is called the "late sodium channel" in heart cells that are suffering from ischemia. Ischemia occurs when tissues aren't getting enough blood. Blocking the late sodium channel improves metabolism in ischemic heart cells. This reduces damage to the heart muscle and reduces angina symptoms. 

People with stable angina are usually placed on a beta-blocker. A nitrate called nitroglycerin is given to treat sudden episodes of angina.

If beta-blockers alone don't eliminate angina, then a long-acting form of nitrate therapy or a calcium channel blocker (or both) are generally added. Ranexa is still a relatively new drug, so it is usually given as a third or fourth drug when necessary. Some cardiologists, however, have found it helpful when added earlier.

Treatment to Prevent Worsening of CAD

In addition to treating symptoms, it is important to find a therapy that will keep CAD from getting worse. This usually means a combination of drug therapy and and lifestyle changes, including:

  • Antiplatelet therapy: Treatment that prevents blood clots can reduce the risk of ACS. For most people this means daily aspirin therapy (75 to 325 mg/day). Plavix (clopidogrel) can be used in people who are allergic to aspirin.
  • Statins: Statins are medications that lower the amount of "bad" cholesterol in your blood. This helps reduce plaque buildup in your arteries. It also helps stabilize existing plaques so they don't rupture and lead to a heart attack or stroke.
  • Risk Factor Modification: Lifestyle changes can also help reduce the progression of atherosclerosis. This means controlling high blood pressure, controlling weight, controlling diabetes, and exercising regularly.
  • Exercise therapy: Regular exercise may also help treat stable angina, though more research into its effectiveness and safety needs to be done. Chronic, low-intensity aerobic exercise like walking or cycling "trains" the cardiovascular system and the muscles to become more efficient. This means higher levels of exercise can be achieved without triggering angina. Ask your healthcare provider if a cardiac rehabilitation program might be a safe option for you.

Other Considerations in Treating Stable Angina

Other lifestyle changes and treatments can also help treat stable angina, including:

  • Reducing chronic stress: The wrong kind of stress can be harmful to anyone with CAD. A stress reduction program may be helpful.
  • Quitting smoking: Smoking can be extremely harmful to someone with CAD. If you smoke, it is important to quit. Ask your healthcare provider about smoking cessation programs that might be able to help you.
  • Enhanced external counterpulsation (EECP): EECP is a unique treatment for stable angina in which inflatable cuffs are worn on the lower limbs. These cuffs create pressure and help blood flow. Studies have shown that EECP can help reduce angina symptoms, but the treatment still has not been widely accepted by many cardiologists. 

Summary

For stable angina, the goal of treatment is to halt or slow the progression of disease, reduce symptoms, and prevent more serious cardiac problems. In many cases, this can be achieved with non-invasive therapies like medication and lifestyle changes.

Invasive therapy may still be used for people with blockages in the left main coronary artery or more serious cardiac disease.

A Word From Verywell

Non-invasive treatments are often equivalent to or better than results obtained with invasive therapy. Remember, though, that CAD is a chronic disease that tends to progress. Work closely with your cardiologist to monitor and reassess your condition. For the best results, your therapy will need to be continuously updated and optimized as time goes by.

9 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Joshi PH, De Lemos JA. Diagnosis and management of stable angina: a review. JAMA. 2021;325(17):1765-78. doi:10.1001/jama.2021.1527

  2. Glazier JJ, Ramos-Parra B, Kaki A. Therapeutic options for left main, left main equivalent, and three-vessel disease. Int J Angiol. 2021;30(01):076-82. doi:10.1055/s-0041-1723977

  3. Sorbets E, Steg PG, Young R, et al. β-blockers, calcium antagonists, and mortality in stable coronary artery disease: an international cohort study. Eur Heart J. 2019;40(18):1399-407. doi:10.1093/eurheartj/ehy811

  4. Camero Y. Management of coronary artery disease and chronic stable angina. US Pharm. 2017;42(2):27-31.

  5. Gurbel PA, Myat A, Kubica J, Tantry US. State of the art: oral antiplatelet therapy. JRSM Cardiovasc Dis. 2016;5:2048004016652514. doi:10.1177%2F2048004016652514

  6. Long L, Anderson L, Gandhi M, Dewhirst A, Bridges C, Taylor R. Exercise-based cardiac rehabilitation for stable angina: systematic review and meta-analysis. Open Heart. 2019;6(1):e000989. doi:10.1136/openhrt-2018-000989

  7. Wei J, Rooks C, Ramadan R, et al. Meta-analysis of mental stress–induced myocardial ischemia and subsequent cardiac events in patients with coronary artery disease. Am J Cardiol. 2014;114(2):187-92. doi:10.1016/j.amjcard.2014.04.022

  8. Centers for Disease Control and Prevention. Smoking and heart disease and stroke.

  9. Braith RW, Casey DP, Beck DT. Enhanced external counterpulsation for ischemic heart disease: a look behind the curtainExerc Sport Sci Rev. 2012;40(3):145-52. doi:10.1097/JES.0b013e318253de5e.

Additional Reading
  • Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 64:1929.
  • Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354.

By Richard N. Fogoros, MD
Richard N. Fogoros, MD, is a retired professor of medicine and board-certified in internal medicine, clinical cardiology, and clinical electrophysiology.