NAPLEX 2026 - Stable Angina

Angina definition

Chest pain, pressure, tightness, or discomfort

Usually caused by ischemia of the heart muscle or spasm of the coronary arteries

Stable angina vs unstable angina

Stable:

Type of chronic coronary artery disease

Associated with predictable chest pain often brought on by exertion or emotion stress

Relieved within minutes by stress or short-acting nitroglycerin

Unstable:

Type of acute coronary syndrome

Medical emergency where chest pain increases

Not relieved with nitroglycerin or rest

Chest pain occurs when...

Imbalance between myocardial oxygen demand (workload) and supply (blood flow)

Demand increases when the heart is working harder due to an increased HR, contractility, or left ventricular wall tension

With stable angina, myocardial oxygen supply is often decreased due to __________.

Atherosclerosis (plaque build up)

Known as coronary artery disease - causes narrowing of the arteries and reduced blood flow to the heart

When chest pain is caused by coronary artery vasospasm, it is called _________ ________.

Vasospastic angina

(or variant or Prinzmetal angina)

Can occur at rest and be caused by illicit drug use (cocaine)

What is included in the evaluation of stable angina?

History and physical

CBC, CK-MV, troponins (I or T), aPTT, PT/INR, lipid panel, glucose

ECG (at rest and during chest pain)

Cardiac stress test/stress imaging

Cardiac catheterization/angiography

How does a cardiac stress test work?

Increases myocardial oxygen demand with either exercise (walking on a treadmill, pedaling a stationary bike) or IV medications (adenosine, dipyridamole, dobutamine, or regadensoson)

Patient is monitored for the development of symptoms (chest pain, dyspnea, lightheadedness), changes in HR and BP, or abnormalities on an ECG

What's included in non-drug treatment of stable angina?

Heart healthy diet

Maintain BMI of 18.5-24.9

Maintain waist circumference < 35 inches in females and < 40 inches in males

Engage in >/= 150 minutes of moderate intensity aerobic activity

Smoking cessation

Limit alcohol

Chronic NSAIDs should not be used

What is the treatment approach for stable angina?

ABCDE

Antiplatelets and antianginal drugs

Blood pressure

Cholesterol (statins) and cigarettes (cessation)

Diet and diabetes

Exercise and education

What is the recommended antiplatelet in stable angina? When is the other used?

Aspirin

Clopidogrel used if an allergy or contraindication to aspirin

Aspirin contraindications

NSAID or salicylate allergy

Children and teens with a viral infection (due to the risk of Reye's syndrome)

Rhinitis, nasal polyps, or asthma

How long should aspirin be used in stable angina?

indefinitely

What form of aspirin is preferred in ACS?

Non-enteric coated, chewable aspirin

Clopidogrel boxed warning

Clopidogrel is a prodrug - effectiveness depends on the conversion to an active metabolite, mainly by CYP2C19

Poor metabolizers of CYP2C19 exhibit higher cardiovascular events

Tests to check CYP2C19 genotype can be used an aid

How many days prior to elective surgery should you stop clopidogrel?

5 days

What medications interact with clopidogrel?

Omeprazole, esomeprazole

What is the clinical benefit of beta blockers as an antianginal treatment?

Reduce myocardial oxygen demand by

decreasing HR, contractility, and left ventricular wall tension

What is the clinical benefit of calcium channel blockers as antianginal treatment?

Reduce myocardial oxygen demand by decreased HR and contractility with non-DHPs and decreased SVR (afterload) with DHPs

Increase myocardial oxygen supply: all CCBs increase blood flow through coronary arteries

What is the clinical benefit of nitrates as antianginal treatment?

Reduce myocardial oxygen demand by decreasing preload (free radical nitric oxide produces vasodilation of veins more than arteries)

Increases myocardial oxygen supply by increasing blood flow through collateral (non-atherosclerotic) arteries

What is the clinical benefit of ranolazine as antianginal treatment?

Selectively inhibits the late phase Na current and decreases intracellular calcium

Can decrease myocardial oxygen demand by decreasing ventricular tension and oxygen consumption

Which antianginal treatment is preferred for vasospastic angina? Which should be avoided?

Preferred: CCB

Avoid: beta blockers

Which antianginal treatment is most effective for silent ischemia?

Beta blockers

What CCBs are preferred to use with beta-blockers?

DHPs (risk of excessive bradycardia with non-DHP)

(Avoid nifedipine IR)

What medications interact with nitrates?

PDE-5 inhibitors

Nitrate warnings

Hypotension, tachyphylaxis (tolerance)

What do you manage tolerance to nitrates?

Long-acting nitrates require a 10-12 hours nitrate-free interval to decrease tolerance

Patch: wear on for 12-14 hours, off for 10-12 hours

Ointment: dosed BID, 6 hours apart

Isosorbide mononitrate: IR dosed BID, 7 hours apart

True or False: Slight burning or tingling sensation with nitroglycerin SL tablets is a sign of how well the medication is working

False

Flushing and headache are often a sign the medication is working (for all nitrate products) - usually goes away with time

What is appropriate way to use nitroglycerin TL spray?

Do not shake

Spray onto or under the tongue (do not inhale)

Try not to swallow too quickly afterward, do not spit or rinse mouth for 5-10 minutes after dose

What is the preferred application site for the nitroglycerin patch?

Chest

(Any area can be selected except the extremities below the knees or elbows)